US rehab industry does not provide evidence-based, effective care.
September 3, 2019 8:24 AM   Subscribe

Kim Blake keeps a folder in her house, swollen with papers. Each document represents yet another try at helping her son Sean recover from a decade of drug addiction... But none of the treatments stuck. In August 2017, Sean died of a drug overdose involving alcohol and fentanyl, a synthetic opioid. He was 27 years old.
Addiction treatment is difficult work, but it can succeed, and evidence-based care does exist. For opioid addiction in particular, studies show medications like methadone and buprenorphine cut the death rate among patients by half or more.

But the parents I spoke to have learned — as thousands of Americans discover each year — that much of the US rehab industry does not provide evidence-based, effective care.

American rehab is dominated by a 12-step approach, modeled after Alcoholics Anonymous, that only works for some patients and doesn’t have strong evidence of effectiveness outside of alcohol addiction treatment.

That’s often coupled with approaches that have even less evidence behind them. There’s wilderness therapy, focused largely on outdoor activities. There’s equine therapy, in which people are supposed to connect with horses. There’s a confrontational approach, which is built around punishments and “tough love.” The research for all these is weak at best, and with the confrontational approach, the evidence suggests it can even make things worse.

“It is a scam,” Carol Beyer, founder of Families for Sensible Drug Policy and a mom in New Jersey, told me. She estimates she spent well over $100,000 on treatment — including 12-step and “tough love” programs — and still lost her two sons to drug overdoses.
Vox is investigating addiction treatment in America. This is the first story.
posted by Homo neanderthalensis (47 comments total) 37 users marked this as a favorite
Thank you for posting this, although it's a heart-breaking story.
posted by suelac at 8:59 AM on September 3, 2019 [2 favorites]

Yes, there's a whole scam industry that's grown up around rehab that's just vicious. Even when not corrupted by "recruiters," far too many rehabs are just glorified day care, except day care workers often care about their charges.
posted by praemunire at 9:04 AM on September 3, 2019 [11 favorites]

When I lived in the US, I led the newcomer meeting for my home Al-Anon meeting. Sometimes people asked me about AA and I made a point of mentioning that some people found it life-saving but others did not, and by the way “12-step programs are not evidenced-based treatment programs” which might have gotten me a lot of shit had any other Al-Anon or AA types been in attendance.

My particular 12-step program has improved my life tremendously and also, I would never, ever pay money to a 12-step rehab program. I nearly did once, for someone I love. The person in question looked at me and said, “you are about to waste thousands and thousands of dollars.” Which was true in that particular case but my desperation made me ready to pony up for treatment.

I do not blame the addicts nor their loved ones for this horrible state of affairs. I blame the grifters who profit so handsomely and who are brought to justice (or regulated or monitored) so rarely. Thanks for the post, OP.
posted by Bella Donna at 9:07 AM on September 3, 2019 [25 favorites]

John Oliver had a good story on just this topic.
posted by jmauro at 9:20 AM on September 3, 2019 [6 favorites]

“It is a scam".

I can't imagine the echoes that have to occur when a person is all but forced to repeat; over and over again; that they are an alcoholic, or that they are an addict.

Brother-in-law did Sean's tour of addiction facilities. Twelve times I believe. Probably had to confess his sins a million times; and swear hundreds of thousands of times that he was an alcoholic, or drug addict. Guy died drunk, in a pile of his own vomit.

These 'treatment' places, they just shrug and pull the 'self-responsibility' routine with their so many failures. AA; well; you've got that one god; the bible god. So much for salvation from Buddha or the rest of the gang. God will help you!

College days - many years ago. Person in one of my classes; never had a drug or alcohol problem; first semester in school for them ever. Employed at Charter Hospital; leading groups and doing one-on-one counseling. Zero certification; zero experience, and although they had some vague concerns about the people they were 'counseling'; yeah. Basically any other schmo off of the street; all of a sudden proffered up as experienced, seasoned, and authority. But they had enrolled in a treatment and addiction counseling program at a college. Big wow.

I can not stop shaking my head over the bilk factor this industry has; and the trail of bodies it leaves behind its rarely fulfilled intentions, slogans, bad psychology, and quackery.
posted by buzzman at 9:33 AM on September 3, 2019 [8 favorites]

I worked at a rehab facility in the late 1970s that required clients attend 12 step meetings as part of the program, but that was just a part of therapy because people working in the field were already aware of the lack of data supporting the efficacy of 12 step programs. However, it was virtually impossible to get funding for addiction treatment without including a 12 step component.

So, when I was looking for a program for my teenage daughter about 15 years ago (the day I learned she had recently started using heroin), I was surprised and disappointed to learn that every single highly regarded residential program within 3 hours of Chicago included the 12 step approach, which I knew would solicit eye-rolls from my atheist daughter.

Fortunately, she was ready to make some changes in her life and did, indeed, stop using all drugs for a few years after spending 6 weeks at the facility. She even attended 12 step meetings after released because, as she said, it was about the only place she could go to hang out with kids she could relate to who weren't doing drugs. However, she always found the 12 step approach to be judgemental bullshit.

Her success at the time was in spite of 12 step, not because of it.
posted by she's not there at 9:39 AM on September 3, 2019 [23 favorites]

Right around when I quit drinking, a book very critical of AA, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, by Lance Dodes, came out. I read it, and, despite its serious problems, I felt that its critique of rehab was pretty devastating (The only other conclusion in the book that seemed warranted to me was that meta-studies of alcohol and drug treatment aren't very good. It had a lot of anecdotes from people who had bad experiences in AA, but, as the author had basically advertised looking for these, it seemed clear that the book was, at best, tendentious on the question of 12-Step programs, and I say that as someone who does not much care for them.).

On preview, basically what Bella Donna said. Many of these places, according to Dodes, don't provide any treatment other than 12-step meetings, which you could go to for free. They are staffed largely by people in recovery who have gotten certificates as addiction counselors, some of whom are actively harmful, with their "tough love" schtick, to people who need actual therapeutic help. I think a lot of what they are there for is to take money from families so they can feel that they have "tried everything".

I have heard from people who found it helpful, though, to be in an isolated kind of sobriety retreat, where there is nothing to do but work on themselves. These people were, or became, strongly motivated toward finding sobriety, which is what it takes. A program or going through the motions in a pseudo-hospital won't change someone who lacks an internal desire to get well. I'm sure that being in rehab helps some people to make that commitment, but, if I had a friend or loved one being more or less compelled to go in, I would not be optimistic for them.
posted by thelonius at 9:41 AM on September 3, 2019 [4 favorites]

A addicted friend killed himself because:

a. he was an atheist who had escaped from an abusive religious family and could not deal with AA;
b. The closest secular group was further than he had gas money for
c. There were no free programs for his other mental health issues that he could get to

So he hung himself, and none of us who knew him have ever really gotten over it. In the years before that we saw his addiction take away so much from him; friends, talent, hope; and he seemed so powerless to stop, that it burned away all my contempt. No one should suffer like that. Addicts are not having a good time. I wish we had stopped treating this as a moral issue decades ago and come up with actual treatments because these folks are already in hell.
posted by emjaybee at 9:47 AM on September 3, 2019 [26 favorites]

Reply All did an episode called The Pain Funnel about this. These places aren’t about treatment nearly as much as they’re about wringing whatever dollar they can get from their client’s insurance or wallet.
posted by gladly at 10:03 AM on September 3, 2019 [11 favorites]

As someone who has used AA for the last six years to stay sober; this is something that has always bothered me about 'treatment facilities' that basically use only the AA model for all addictions. The way alcohol, opioids, benzos and stimulants (like cocaine) affect the brain chemistry is vastly different from each other. Why is the single size fits all the ONLY option at these facilities?

I am an alcoholic. I have never tried drugs other than alcohol in my active addiction. But even someone like me can see how other drugs will affect me differently than alcohol. So why is AA meeting the only option for so many folks who are struggling with addiction to things other than alcohol? My only answer is that because AA is essentially free. These 'treatment centers' are scams that take money, get people 'cleaned up' for 30 days or whatever time insurance pays; and then release them to the 'care' of AA. The fact that there are drugs that help with recovery, should be an integral part of rehab. The fact that it is not is really baffling.
posted by indianbadger1 at 10:07 AM on September 3, 2019 [11 favorites]

People tell addicts that they have a disease, but they treat it like a moral failure. The twelve step programs are just another manifestation of that. You're an addict because you're weak, because you have poor values. You need a nice shot of Jesus and his daddy to get yourself right.

I hate all of it.
posted by metagnathous at 10:10 AM on September 3, 2019 [9 favorites]

I have been heartened to see that hospital-based Intensive Outpatient Programs are becoming more accessible as insurance companies slowly diversify from scam rehab, especially as IOPs for addiction are usually oriented to dual/multiple-diagnosis methodologies and I don't believe addiction is ever a freestanding solo diagnosis.

But the one thing scam rehab offers that most other insurance-covered evidence-based programs do not is housing during treatment, which I do believe is critical for success for people who are either insecurely homed or just really need to not be living in their usual place as a facet of their treatment. These places get so much money out of the parents of young adults just because they get the kid out of the fucking house (and away from toxic parent-child dynamics), or the dangerous parent out of the household with younger children, because that urgently needs to happen. It just unfortunately gets nothing else done. At this point hospital beds are too expensive, and group homes/sober housing is not yet at a place where they are reliably not scams of their own, so an IOP is a great improvement in treatment but is insufficient for some people (and of course inaccessible in many cases to people with jobs and not piles of savings).
posted by Lyn Never at 10:15 AM on September 3, 2019 [9 favorites]

Between this and their series on medical billing, Vox is doing really good work trying to shed light where it is needed.
posted by salvia at 10:38 AM on September 3, 2019 [14 favorites]

I quit drinking because of negative health effects / getting older. I can’t imagine how people who quit because of alcoholism maintain the strength necessary to stay sober. Sometimes it feels like alcohol is a god worshipped by our culture. The degree to which alcohol is involved in daily life seems so completely warped now that I don’t use it. I would imagine 12 step meetings or inpatient facilities are useful just because they’re the rare places that shut out or counter the cultural message that regular humans can’t get through the day without drinking.
posted by sallybrown at 10:57 AM on September 3, 2019 [13 favorites]

I can’t imagine how people who quit because of alcoholism maintain the strength necessary to stay sober.

Well, it gets easier. I hardly think about it now, after almost 8 years. The first year is really hard, and the second is hard too, in a different way. But you get used to it. As to where I found the strength to do it, it was mostly getting scared shitless about how close I was to experiencing full-blown, shakes in the morning, coming to consciousness in a jail cell and not knowing if you killed anyone with your car, dying of organ failure alcoholism. It hadn't gotten to where I needed medical detox yet, though. I used to sober up for a couple of days after a serious drinking episode. Does that mean I was a "binge drinker", not an "alcoholic"? I really don't care - I started thinking of myself as someone who really, really needed to stop drinking.
posted by thelonius at 11:08 AM on September 3, 2019 [9 favorites]

I'm writing this from the balcony of a friend who is going through final doctor-supervised withdrawal from a substance with opioid-like effects, after a prolonged period of dosage-lowering over time, and have been keeping an eye on them full time since Friday with an as-yet-unknown end date.

With the support of a significant number of prescriptions to manage symptoms, it's been a tough process for them, and the one day they thought they were doing great and wanted to skip the support meds, it took about six hours before they started feeling some of the the unmedicated withdrawal symptoms, and it was...not good. They're back on, and the process continues.

12-step programs may have their place, but I cannot begin to imagine a scenario where someone could successfully get themselves through this part of the process -- and stick to it -- without attentive and thorough medical support and supervision, and 12-step programs are not that.
posted by davejay at 11:10 AM on September 3, 2019 [7 favorites]

I am a little over one year sober. I went to a 12-step based treatment facility based on a recommendation from my doctor. My blood test had revealed very high liver enzyme numbers, and I had expressed an interest in stopping drinking.

The treatment facility recommended I check in for detox based on an interview with me. I called my doctor and asked him if he agreed with this assessment, and he said he would follow the recommendation of the treatment facility.

So I checked in for a week of detox. It wasn't bad, but it wasn't only for alcoholics. The facility also provides psychiatric care, and others in the detox area were there for other substance abuse, so it was a lock-in situation in rooms that were carefully designed around being unable to self-harm. I did not experience any sort of withdrawal symptom of any kind. I am still unsure if I really needed to check into detox.

I spent one week there, and followed that with another 5 weeks of daily outpatient therapy sessions at the facility, but they strongly encouraged me to check into their onsite residence.

I found the group therapy discussions to be helpful. The seminars were also informative, giving me some insight into how alcohol abuse affects the brain chemistry and can be hard to kick. The 12-step stuff I found tedious, and very much religion and shame and guilt and responsibility based.

"But you can believe in anything you want!" they tell you. But they insist on finding a higher power. And you have to pray to this higher power and ask it for help and to take away your desire to drink or use substances. There's nothing there at all for us atheists, who do not believe in an invisible sky man to magic away our problems. The AA book talks about this issue but atheists are shushed with words about how you're not as smart as you think you are and look at all these people who have had success with AA!

I went to AA meetings for 90 days. I had a sponsor. He seemed very supportive at first, but he wanted to do what I thought of as a "speed run" of the 12 steps. I wanted to do things at my own pace and talk about how I felt. The first time I talked about how I was not a binge drinker (I drank consistently and regularly, daily, but not in binges) and how I could go to an office party and maintain "some" control of myself, I was shut down and told in AA you have to admit you have NO control. I was not allowed to discuss how I felt that my drinking was habitual, not compulsive. I was not allowed to talk about how I did not have cravings, I was told "you will."

My sponsor dropped me just as I reached that 90 day mark because I wasn't doing the 12 steps as fast as he wanted. I didn't go back to that AA group because it felt so much like going to church, as I had been forced to do as a kid. They tell you that you can believe in anything you want, but every meeting begins and ends with a prayer to the Christian god.

So yeah, it's been a year and almost one month. I still don't desire to drink. I feel much better. I still haven't had any cravings. I feel very lucky about that, as I understand many people do have strong cravings. I also feel lucky that my friends either have also stopped drinking or just don't drink very much at all anymore, being middle aged.

A lot of my own sobriety has been based on mindfulness of how I am feeling. One of the things they talked about in my therapy was HALT - Hungry, Angry, Lonely, Tired - being triggers for reaching for a substance. I think through how I am feeling a lot, and remember that there is no problem I have that alcohol won't make worse.

I wish AA had allowed me to talk about my own things in my own way and get some real insightful feedback, but they seemed more interested in reciting their doctrine. Here, say these things and chant these phrases with us! Religion!

I wish peace and strength to everyone who is struggling with substance abuse.
posted by Fleebnork at 11:40 AM on September 3, 2019 [35 favorites]

he wanted to do what I thought of as a "speed run" of the 12 steps

I never understood this mentality...If someone took the steps sincerely, it might take quite a while indeed to go through them. I could imagine, for example, it taking a long time for someone to truly come to believe, not simply assent to, the idea that their Higher Power could "restore them to sanity".
posted by thelonius at 11:48 AM on September 3, 2019 [1 favorite]

The problem with anecdotal evidence about AA is that AA meetings vary considerably in quality and approach. Some are little more than come-to-Jesus rivals, some more opening to sharing and cross-talk, some cold, some are welcoming. You can't draw a conclusion from a sample size of one.

That said, AA's main hang-up, for me, is that it stuck in the 50's and strongly resists any of the research that has been done since the Big Book was written on the subject of addiction in general and alcoholism in particular.

AA's greatest strength is that it brings you into contact with other addicts, who are the only people who seem to understand the problem from the inside. Doctors, clinicians, counselors are all fine, but only folks who know what it's like to be fighting their own brains really seem to "get it."
posted by SPrintF at 12:10 PM on September 3, 2019 [10 favorites]

I am an alcoholic who doesn't drink and an atheist. Over twenty years or so I have done IOP, NAD therapy, hypnotism, individual therapy, AA and read have read many books with different approaches. I would say I got something out of all of these, except NAD therapy and hypnotism, but that's me. It took years and continues to be a work in progress. Thinking progress not perfection helped a lot. Hearing stories of instant revelation and recovery made me feel discouraged. I didn't agree with all parts of any one treatment but took what helped and left what didn't. Sometimes a second go around made things click that didn't the first time. I gave up often but would try again. I hated AA until I didn't. I don't believe in god but that isn't necessary to go to AA. It's god as you understand him, whatever that may be. To me it's acknowledging I couldn't do it by myself. If you can do it by yourself then you don't need AA. I like AA and my sponsor, she's amazing. It took a long time, but it was worth it to keep trying. AA helps me now, I don't know why.
posted by waving at 12:32 PM on September 3, 2019 [6 favorites]

The way I found my private practice buprenorphine doc was:

a.) she picked up the phone, herself
b.) in the first conversation we had when she did, she agreed with my assertion that rehab seemed to be, quote "bullshit."

Maybe she had a certain self-interest in saying that. And it only worked as a option for me because I could afford a monthly appointment that's not covered by (my) insurance and not all that cheap. But even on that front it's gotta beat a lot of programs out there.
posted by atoxyl at 12:55 PM on September 3, 2019 [1 favorite]

I think people experience AA differently depending on the kinds of meetings they attend. I am fortunate to be in a city that has so many meetings, so many kinds of meetings, so many different kinds of people that go to those meetings; I am amazed sometimes. Hearing other people's bad experiences with AA only makes me feel that much more grateful.

With that said, I have heard good things about SMART recovery based on CBT ideas; that has no 'god' in its practice. I tell this to people I meet in AA who just don't like the program but are there because of circumstances. Also about sponsorship; I have always told the people I sponsor that it is their recovery. I am here to help. I have never understood Sponsors who are 'hardass' about it.

All this is to say; if you or anyone you know is trying to get sober; I hope you find something that works for you. If AA was the only/first thing that you were offered and it did not work; please explore other options. I am in AA and it is working for me, but I only know this only for myself; and I am an alcoholic. If you are dealing with other substances in addition to alcohol; the Vox article is a sobering truth about the ineffectiveness of 12 step only.
posted by indianbadger1 at 1:09 PM on September 3, 2019 [2 favorites]

12 Step is like many systems - it's the worst one we have, except for all the others we've tried. It has helped plenty of people, which makes it the most successful by default.

AA is like any other cross-section of humanity. You'll meet some nice people and some assholes. You'll meet Bible/Big Book-thumpers and laid-back non-traditionalists. Some meetings are big on Jesus, but I've also gone to meetings that went out of their way to be trans-inclusive (and it wasn't an LGBT meeting, which also exist).

If you're an introverted atheist like me, you might have to work harder and go to more meetings to find your people. That can be a drag.

I think the opposite of addiction is connection. That's the most important thing AA provides, and what SMART and IOP rehab did not, for me. Connection to God, or to a purpose (keeping others sober), or simply to a new group of friends. It was the latter that finally got me sober almost 4 years ago.
posted by frogstar42 at 1:48 PM on September 3, 2019 [2 favorites]

12 Step is like many systems - it's the worst one we have, except for all the others we've tried. It has helped plenty of people, which makes it the most successful by default.

I very strongly disagree with this. I see what you're getting at, but this is just not correct. And it is very much the sort of justification that is repeated at AA/NA meetings. And it costs people their lives.
posted by booksarelame at 2:27 PM on September 3, 2019 [17 favorites]

I just want to mention that Al-Anon , my 12-step program, has worked for me because I’ve been able to find meetings that included other atheists and members who absolutely accept non-religious folks. For the purposes of the program, my higher power is reality. I absolutely do not control reality and I am in denial when my behavior is not grounded in reality.

Of course, I have the good fortune of being in a 12 step program that encourages people to take what they like and leave the rest. I don’t know for sure, but my impression is that AA members don’t have that same luxury. I also have the impression that some AA folks are kind of macho or can be. Which can be really effective for some people and completely useless for many others. In short, 12-step programs are a land of contrasts. Please put on your own oxygen mask first, and practice self-compassion as much as possible. I salute all who beat any type of addiction. It can be done but tain’t easy.
posted by Bella Donna at 2:49 PM on September 3, 2019 [5 favorites]

I have been sober 10 years and still believe that going to AA saved my life because if I had continued with my plan, which was to just not drink anymore, I would not have been successful. Everything said for and against AA is true. There is no magic button, although there is hope for some medical remedies. I don't go to meetings anymore, haven't for several years, although I was pretty deeply involved for awhile as a way of paying back. I have always abhorred true believers of any sort but, hey, if that's what keeps you sober, good on ya. There are snake oil salesmen in every human endeavor, including addiction treatment. It's all anecdotal because AA as an organization is basically the closest thing to anarchy that I know of, one of its greatest strengths. I miss my buddies, but I have lots of other buddies. Whatever works and keeps you from driving drunk into my car on the highway.
posted by kemrocken at 2:54 PM on September 3, 2019 [2 favorites]

As Joey used to say, "You have to learn to tell the shit from the ice cream". In spite of the many religious references in our 80 year-old big book, AA is NOT a religion. Yes, especially in America, there are lots of chatty believers but, like Dorothy used to say, "What do you do when you meet a whirling Dervish? Let 'em twirl".

It was, after all, an atheist who insisted Bill include the phrase, “God as we understood Him” in Step 3. There are also plenty of people with other religious persuasions as well as lots of atheists, agnostics, and free thinkers in the program, including me (33 years) and my partner (30 years).
posted by chance at 3:04 PM on September 3, 2019 [2 favorites]

AA is free. AA's suggestion to believe in a higher power includes the option of believing that the collective wisdom of the group is more informed than one's own singular opinion. This is mentioned often. AA is not evidence based mostly because it takes anonymity very seriously. Some studies were done with WWII soldiers that showed promising results. Lately, studies have shown it to be less successful than it was. Personally, I think the higher power stuff is too old fashioned and too much of a hurdle for many contemporary members.

But there are some good reasons for the approach. Alcoholism will often present itself as a kind of narcissism. The alcoholic's ego must be deflated (or re-inflated at times) by reacquainting them with their sense of community and common humanity. The tendency towards aggravation, resentment, remorse, or guilt can be tempered through meditation, prayer, and renewed focus on the present moment. There is an emphasis on building a "toolbox" to deal with catastrophic or otherwise irrational thinking. In other words, there is a lot of psychology at play in the program albeit in the guise of spiritualism.
posted by xammerboy at 3:43 PM on September 3, 2019 [6 favorites]

With that said, I have heard good things about SMART recovery based on CBT ideas; that has no 'god' in its practice.

I always liked Jack and Lois' model, but man, I understand how the bystanders couldn't deal with him taking AA head-on and needed to fork the program.
posted by mikelieman at 4:18 PM on September 3, 2019

Vox is doing really good work trying to shed light where it is needed.

I am ... not so sure in this case. As I mentioned earlier, AA is not a money making scam. AA is not evidence based, but suggesting that twelve step programs are largely unsuccessful is a problematic accusation. Alcoholism is today considered a treatable disease largely because of AA. Before AA, alcoholism was considered a death sentence, and the treatment was often a forever stay at a sanitarium. The simple fact that it's now widely considered treatable speaks to AA's historic success.

I have seen people pay through the nose for very expensive treatments that included moderated group talk therapy, CBT, one on one counseling, etc. who later came to the conclusion that most of what they were paying for was available through AA. By lumping a free service that provides virtually the same treatment as very expensive top of the line hospitals in with other grifting scam services, Vox could be doing a lot of people in need a disservice.

Also, I am skeptical of some of the more evidence based treatment programs. Many of them are primarily about avoiding triggers and strategies for de-triggering once triggered. The AA program, on the other hand, does not ask members to avoid alcohol. The program is focused on re-orienting behavior so that one does not experience a desire to drink on a one day at a time basis. It doesn't work for everyone, but escaping this constant desire is a qualitatively better outcome, in my opinion, than managing it.

Then there is the means. Some of these programs are based on a reflective practice of identifying triggers and thought patterns that lead to drinking, methods for avoiding alcohol and defusing social situations that include alcohol. AA is based on a practice of moral and psychological self improvement in all areas of one's life. Whichever method you choose, it's a life practice, but one includes regularly thinking about avoiding drinking, and the other regularly thinking about how to best live one's life.

I don't mean to knock any program. Whatever works is what's best, and is a blessing. But there are some distinct advantages to the AA program that Vox is not recognizing. Also, they are disparaging a program that has done a lot of good, and could be discouraging some people from exploring the only affordable and or available path to managing their illness of dependency.
posted by xammerboy at 7:29 PM on September 3, 2019 [4 favorites]

they are disparaging a program that has done a lot of good

Sadly the numbers do not bear that out, and the basis of AA is a religious quack from 30's. The one reason AA became successful was the revolutionary fact that it treated addicts like people. The fact that it has survived at all into this century is not a testament to it's working- it's a testament to how nothing better has replaced it yet. Even if it's success rate is the abysmally low 19% some claim it to be, that's better then 0% so it remains. It's time to use evidence based medicine to treat addiction, not folk wisdom that is unproven at best, harmful at worst.
posted by Homo neanderthalensis at 8:07 PM on September 3, 2019 [12 favorites]

AA is not itself a moneymaking scam but you'd be surprised at the way grifters can attach themselves to any institution. In this case, using it in expensive rehab as a substitute for...well...anything that might cost them more.
posted by praemunire at 9:07 PM on September 3, 2019 [4 favorites]

I tend to see AA more as psychology utilizing the path of spiritualism. For instance, the alcoholic will experience profound guilt and regret over past experiences that people who are not alcoholic would not. Alcoholics awake from blackouts and then confess to unsolved murders or other crimes they did not commit out of feelings of remorse. The alcoholic is more remorseful generally. Whether this is due to some kind of brain damage or prolonged exposure to an alcohol induced fugue state is not known.

In AA, the treatment for this aspect of alcoholism is to make amends for past acts, and immediately admit to wrongdoings in the future. In CBT, the treatment is ameliorate guilt by re-assessing the past acts in a neutral and logical manner. These are both logical techniques for addressing the feelings of guilt and remorse that naturally accompany alcoholism. One happens to be labeled religious and the other scientific. There's no reason not use both techniques simultaneously.

There's also the question of what evidence means when assessing these programs. My understanding is that the basis for evidence is whether or not the alcoholic self reports as cured. This is problematic in the case of alcoholics, because the disease is linked to a tendency to self deception generally and outright deception when reporting to authority. An alcoholic would be more generally likely, in my opinion, to self report a prolonged treatment as successful that involved one on one therapy with a clinician than one self administered, even if the treatment failed.
posted by xammerboy at 9:58 PM on September 3, 2019 [1 favorite]

Also, to be clear, the main subject of the article reporrtedly had addictions to alcohol, cocaine, and opiods and that he died of a fentanyl overdose. The article does state that 12-step programs have been found useful for some people for alcoholism but also states that the evidence of 12-step programs' efficacy for non-alcohol addictions to be much weaker.

In fact, one of the key things they're pointing out in the article is that there are known and effective medications for treating opiod addiction but their availability is generally poor and, in fact, actively discouraged in some of the 12-step-based treatment facilities ("replacing one drug with another").
posted by mhum at 10:19 PM on September 3, 2019 [5 favorites]

It was, after all, an atheist who insisted Bill include the phrase, “God as we understood Him” in Step 3. There are also plenty of people with other religious persuasions as well as lots of atheists, agnostics, and free thinkers in the program, including me (33 years) and my partner (30 years).

I am happy if you have found success within the AA system, and I hope it continues to work for you.

I find the very phrase irritating. There isn't a God, or an "as we understood him". There's no "higher power" to magic away the problems. This is THE major obstacle for me and AA, because the entire thing hinges on getting you to believe in a higher power.

Step 2: Came to believe that a Power greater than ourselves could restore us to sanity.

"You can believe anything you want!" I am not a believer. There does not exist this non-real thing in which to believe. I do not "believe" in invisible non-real things.

Steps 2, 4, 5, 6 and 11 are all based on believing in a higher power.
posted by Fleebnork at 7:18 AM on September 4, 2019 [9 favorites]

There isn't a God, or an "as we understood him". There's no "higher power" to magic away the problems.

Do you believe in gravity? The physical laws of the universe? Are you part of society whose rules you sometimes have to adhere to whether you like it or not? That some things happen in the world without you being responsible for them? Do you have a boss who expects you to do what he asks sometimes even if you disagree?

The narcissist will vacillate between extreme highs and lows based on a fantasy that they are responsible for everything that is happening in their world. If things are going great, it's all because of them. If things are going badly, it's either because they are not getting their way or often, again, all because of them.

When you say you find being asked to believe in a higher power offensive I get where you are coming from, but god or magic is not really the issue here. Alcoholics have trouble believing in the validity of and connecting to the world outside of them - period. This includes being a part of any group collaboratively, as opposed to being in charge.

Look at Trump. The stock market has gone up and it's all because of him, because he is the greatest president of all time full stop. If it goes down, it's only because no one listened to him. If it crashes, my expectation is that he will too, because it was all on him and he failed big time - even if it was only because no one listened to him. The ecstasy and agony of being Trump.

Any way, the suggestion (all the steps are suggestions) that one believe in a higher power has a low bar, but some kind of spiritualism is strongly recommended. This is because of the utility of spiritualism, which historically has been used to achieve humility, recognize a larger reality, connect to community, and adhere to a behavioral code. In this case, that's a higher power and code of one's own design. Again, a pretty low bar.

Personally, I am an atheist. I think I've already said I think the way the higher power thing is referred to in AA is old fashioned and too big a hurdle for contemporary addicts. If it were up to me, I would change it. Most of the people I see fail to complete the program do so because of the higher power suggestion. It has become a problem, in my opinion, which is a shame. I do though recognize its psychological utility.

Anyway, I have got to apologize. I fear I've monopolized this thread. Unless someone addresses me specifically with a question I'll bow out.
posted by xammerboy at 7:58 AM on September 4, 2019 [2 favorites]

I'm an addict in a 12-step program. I'm not an alcoholic and the program is not AA. I've also been sober - not participating in 'bottom line' behavior - for 20 1/2 months. I do not believe that I would have stopped 'acting out' were it not for my program.

The particular 12-step tradition I'm in makes sure to point out that every meeting is different. Especially in large metropolitan areas, it's easy to find multiple appropriate 12-step meetings every week, even multiple meetings every day. One does not have to stick with the first meeting, or first tradition, that one encounters, especially if the content of that meeting doesn't speak to you.

We also repeat the Al-Anon mantra, "take what you like and leave the rest". If you don't believe in a singular Higher Power (and I don't), there are still ways to work the steps. As mentioned above, many people find "the fellowship itself" to be a good working substitute for a Higher Power. There's also a great book, _One Breath at a Time: Buddhism and the Twelve Steps_ (link goes to Kindle edition) that reframes the AA spirituality into a non-deistic paradigm.

The thing to remember is that addiction really isn't so much about the thing that you're addicted to. Johann Hari has an EXCELLENT TED talk where he discusses, among other things, the Rat Park experiment. The conclusion he comes to, and which I agree with, is that the core of addiction is lack of connection - to people, to the world, to yourself. My program gives me a place to work on connecting with people, through meetings and service and sponsorship, and that gives me what I need to not want to escape

Does 12-step work for everyone? No. Can it be a helpful part of a journey to sobriety? Absolutely. Are there grifters turning 12-step into a way to profit without caring about results? Probably, yes, unfortunately.
posted by hanov3r at 8:24 AM on September 4, 2019 [3 favorites]

I can identify with the woman profiled in the article. I, too, had a son, dead now about a year and a half from a fentanyl overdose. Our detox/rehab saga was not as long or as expensive as theirs but the outlines are broadly similar. We were at least sophisticated enough to know from before the beginning that a detox/rehab cycle is not a "cure," though it turned out that this knowledge was not good for much.

One point in the article that nobody seems to have thought worth noticing: in the US, the lack of medication-assisted treatment for opioid dependence is a crime against humanity. Where methadone or other drug-replacement therapy exists at all, it's either underresourced to the point of uselessness (months-long waiting lists to get an appointment to be evaluated, sometimes) or a profit center for sleazy-seeming private practice doctors. With a side helping of stigma ("replacing a drug with another drug") and a puritanical insistence on getting the patient off the maintenance medication ASAP.

If there's ever to be a solution to the current prevalence of opioid addiction that doesn't involve just letting all those addicted people die, it's going to have to include long-term (even lifelong) maintenance on methadone or buprenorphone or something similar. One goal ought to be that if someone presents for opioid addiction treatment, they will to be able to get on a safe medication to keep them from getting dopesick right away. And, as the article pointed out (and someone upthread also observed) addiction is probably never a single diagnosis: one benefit of universally-available medication maintenance therapy would be that the patient could start getting help with whatever other issues contributed to their becoming addicted in the first place, without which help they're probably never going to be able to live a normal life.
posted by Aardvark Cheeselog at 9:16 AM on September 4, 2019 [15 favorites]

Oh, and something else: if you or someone you know is struggling with addiction and cannot stomach the Abrahamic monotheist basis of AA, do take a look at Refuge Recovery, if you are fortunate enough to live in a place where it is offered. It is inspired by Buddhist teachings, but it's more Buddhism-as-psychological-technology than Buddhism-as-religious-belief.
posted by Aardvark Cheeselog at 9:21 AM on September 4, 2019 [2 favorites]

I am so sorry for your loss, Aardvark Cheeselog. I cannot imagine your heartbreak, I just know it is immense.
posted by Bella Donna at 10:17 AM on September 4, 2019

The narcissist

This is more AA ideology. It's part of the "Higher Power" concept, and can't really be used to justify it without circularity. And one of the least well-supported pieces of the AA worldview is the notion that alcoholics are markedly self-centered, narcissistic, or suffering from "self-will", whatever that is, more so than non-alcoholics. Antisocial personality disorder has been found to be slightly more common in people with alcohol use disorders, than in the general population, but mostly personality types are distributed about equally. A good proportion of people who tried AA and didn't like it perhaps felt that way because they didn't care for being told that they were controlled by personality disorders that they don't have.
posted by thelonius at 10:29 AM on September 4, 2019 [7 favorites]

Do you believe in gravity?

No, I do not "believe" in gravity, it exists as a measurable force and it keeps me from floating away. If I refused to believe in gravity I would not then float away.

The physical laws of the universe?

“The good thing about science is that it's true whether or not you believe in it.”

― Neil deGrasse Tyson

Are you part of society whose rules you sometimes have to adhere to whether you like it or not?

Yes, breaking those rules results in real consequences like fines or jail.

That some things happen in the world without you being responsible for them?

Sure, yeah.

Do you have a boss who expects you to do what he asks sometimes even if you disagree?

Yep. If I don't do what my boss expects, I will get fired. I exchange my effort and compliance for money and benefits. This does not require me to "believe" anything that is not real.

The narcissist

This is more AA ideology. It's part of the "Higher Power" concept, and can't really be used to justify it without circularity. And one of the least well-supported pieces of the AA worldview is the notion that alcoholics are markedly self-centered, narcissistic, or suffering from "self-will", whatever that is, more so than non-alcoholics.

Thank you for stating this succinctly. My response would have been far less polite. I don't appreciate being accused of narcissism by randos on the internet.

Again, one of the big turnoffs for me is the AA big book exhibits the same kind of circular reasoning used in religion (or at least Christianity, which is the only religion I was forced by my parents to attend) and it was part of my distaste for it going in. The big book has these ever-so-pat dismissals for atheists tidily written up, "Ha-ha! gotcha atheists!" Except the gotcha logic only works for believers to feel smug, not to convince us non believers of anything.

I understand that AA evangelists really want to spread the good word, but the literature and accusations of "narcissism" really should take care not to insult people who might need some understanding and compassion.

The AA true believer stuff very quickly turns any non-compliance into accusations and drum-beat tropes of "taking responsibility". It's how they avoid taking responsibility themselves for turning away people who have doubts in the AA system.
posted by Fleebnork at 11:49 AM on September 4, 2019 [7 favorites]

I think AA can be very helpful to the right kind of person. It will never be the one size fits all that courts and others have tried to make it, to the detriment of countless people. Meetings that are LGBT inclusive and agnostic are exceptions, not the rule, and damage can be done before finding the exceptions if they're nearby.

I'm genuinely very happy the program helps the people it does (my dad swears by it and is going on 3 decades of recovery), but there's a reason the twelve steps say "God as we understand him." and not "God as we understand God" or "a power greater than myself as I understand it." It's cool if that doesn't bother you as a person, but it's pushing patriarchal religious/world views that are inherently damaging to those it does bother. It's up to the individual seeking help to adjust to god being whatever they want even if they hear god referred to as a man several times a meeting while posted on the wall. This cannot be hand waved away. It matters and it's one of a few reasons I would never recommend AA outright to anyone (but I would support them!).

I think the 12 steps are very useful. The ACA program might've saved my life, and it uses twelve steps. Though they've been modified and the relevant step is changed to "God as I understand God" or "a god of our understanding." Having concrete steps to recovery can be good. Having a group of people to commiserate and rely on is good. Having literature about how others have coped is good. There's a decent clip of bad baked in that hasn't been expunged, but there's good there too.
posted by avalonian at 12:29 PM on September 4, 2019 [1 favorite]

I think the 12 steps are very useful. The ACA program might've saved my life, and it uses twelve steps. Though they've been modified and the relevant step is changed to "God as I understand God" or "a god of our understanding."

Multiple twelve step programs, including many AA meetings, use that wording, rather than "as we understand him".

There's some really telling stuff in the article. The fact that his bipolar disorder and possible PTSD weren't caught until very late in his cycle, after multiple attempts at rehab, speaks volumes about the lack of quality to the care they paid for. But that's not a stigma on AA or other 12 step programs in general - every meeting I've gone to, in any fellowship, has highlighted the fact that we are not professionals, and that professional therapy is also incredibly helpful.
posted by hanov3r at 1:46 PM on September 4, 2019

I work part-time as a nurse in a drug treatment program where residents are offered medication assisted treatment and regular access to mental health care but are also strongly encouraged to attend 12-step meetings. On the side, I volunteer with a hard-line harm reduction group distributing clean syringes, wound care supplies, and narcan. I have so many thoughts on this whole destructive cycle.

-There’s an idea out there in the treatment world that all harm reductions advocates (that is, people who support syringe exchanges, supervised consumption sites, and other policies that do not promote abstinence but do reduce negative consequences of drug use up to and including overdose) hate 12-step programs and want them banished completely. This is emphatically not true. What all the advocates I work with hate is compulsory 12-step meetings required by treatment facilities and/or courts, and the idea that the steps are a substitute for evidence-based medicine. All would acknowledge that meetings are helpful supports to some and would not want to cut people off from a resource that helps them. Meanwhile, 12-step advocates are not doing themselves any favors with gross memes like this. I know, each meeting operates independently, if you don’t like one try another, etc, but to me the fact that any group leader can promote such harmful, stigmatizing bullshit means the group as a whole needs to take a hard look at its values.

-That said: public health and harm reduction have an image problem. All the scientific evidence supports lower barries to MAT, easily accessible syringe exchange, etc, but as providers we can get so enthusiastic about the evidence that we forget that folks can have a deep, visceral reaction to anything that seems like “enabling” drug use. This thread touches on some of the problems clinicians have talking to those who oppose harm reduction measures, and I wish I could go to the author’s talk.

-Related; in my area, some of the opposition to MAT and other non 12-step interventions for opioid use specifically comes from black community leaders in areas that were hard-hit by crack, saying “where were you when people in our communities were dying?” (More POCs have died of opioid overdoses in my city than white people, so this concerns speaks to the overwhelming whiteness of opioid coverage as much as anything, but I digress). As a white provider, the only honest answer I can give to this line of argument is to acknowledge that white policy makers, medical professionals, and recovery advocates all fucked up badly, but that reconciliation to me means increasing access to treatment resources now rather than doubling down on punitive approaches. At least in the US context, any recovery efforts that don’t have racial justice at their core are missing a crucial piece.

-All of these tensions are playing out in really interesting ways at my work right now. My facility is a longer-term residence where patients who were homeless prior to admission live for several months while simultaneously detoxing from substances/starting MAT/going to therapeutic groups, some 12-step and some not, and also looking for stable housing. Relapsing does not get you removed from the house immediately. I have heard other staff members complain repeatedly about “the city forcing all this harm reduction stuff.” Apparently not being able to kick people out for using is a new policy, and the staff are afraid that neighbors will complain about residents walking around intoxicated. I’m new myself and don’t want to have immediate disagreements with established staff, so I haven’t said anything, but I’m inclined to think that the neighbors who would complain about people walking around high are the same ones who would complain about living next to a treatment facility under any circumstances. To blame harm reduction for that is victim blaming; it reminds me of the folks saying that right-wingers get pushed further right because there are too many genders on tumblr. That said; if the city is pushing harm-reduction oriented policies without offering any support to staff beyond “here, new policy, you can’t kick people out now,” that is a problem, especially if the facility was previously more 12-step oriented and views relapse as a moral issue. If we are going to embrace MAT and other evidence based approaches, it needs to be wholehearted and come with appropriate training for all providers.

I don’t really have any good conclusions here, just condolences for all the families and friends of those lost to overdoses. There are so many tools and treatments out there that could have averted this crisis, all deliberately mad hard to access in the name of humiliation and punitiveness disguised as safety concern. It’s so discouraging.
posted by I am a Sock, I am an Island at 1:47 PM on September 4, 2019 [13 favorites]

I do want to make myself very clear that I have been only speaking for my own personal experience with AA and not trying to dissuade anyone from trying to seek help from 12 step systems. I am sure there are plenty of good organizations and groups out there.

I think there is an unfortunate thread of religion and a dash of shaming or “personal responsibility” stuff that exists in some AA groups and unfortunately I ran into it. Some updating of the literature and modernization would be good in general. And it’s my personal opinion that some alternative to the belief in a higher power thing needs to be considered.

But by all means, seek help if you need it, and I wish everyone peace and strength who are struggling with substance abuse.
posted by Fleebnork at 5:19 PM on September 4, 2019 [1 favorite]

As much as I'd like to disagree with this article, unfortunately it is true. Granted some of the treatment facilities are evidence based, most are in it for the money being that there is plenty of families willing to pay whatever amounts necessary to cure their loved ones addictions. I own landscaping company and have seen many of my employees fall to addiction, most trying some sort of rehab that usually doesn't work. The odds are against them and I do hope to see more evidence based facilities in the near future.
posted by Gagarab at 8:39 AM on September 12, 2019

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