The Truth is sooooooo Tasteless – The case of Gabrielle Glaser and the dueling Cochrane Reviews

Gabrielle Glaser released a big story in The Atlantic this week dissecting AA, and obviously, dissing it as well. The article was well researched and presented a lot of hard facts. As usual, this was portrayed as insensitive and malicious by the recovery culture. How dare you attack a program “that has helped millions” (it hasn’t helped millions, but we’ll talk about that later).

New York Magazine said that Glaser’s article “was a little bleary on the science” and placed it in the “Highbrow” yet “Despicable” quadrant of their famous “Approval Matrix” – their “guide to who falls where on our taste hierarchies.”

Glaser’s article sits on the matrix directly under a story about an artist who threatened to go into a museum and urinate on other artists paintings. That’s right – she wrote an 8,000 word article detailing mounds of research demonstrating the massive problems with 12 step programs which are:

1) foisted on millions of people every year (many against their will) in a supposedly medical treatment system (even though these programs are faith healing)

2) statistically don’t work

3) are nonetheless supported by our government

4) and may actually hurt the people they are intended to help

…and yet the New York Magazine classifies it as almost as despicable as walking into a museum and pissing on the artwork. Moreover, it falls slightly further left on the despicability end of their spectrum than the fact that baby wipes are clogging up municipal septic systems.

Yes, a detailed exposé of a systemic failure that is hurting and probably hobbling countless people in our country is equivalent to piss and shit according to New York Magazine. It rubs them the wrong way. It is tasteless. But what pleases their tastes?

On the “Brilliant” end of the spectrum? A football player on Dancing With The Stars; A woman who left a movie premiere barefooted; a book of poems; and a storyline on HBO’s Girls.

“These are just delightful and tasteful moments aren’t they? Just wonderful…… Oh, we’re treating millions of people like trash and dumping them into antiquated meetings that only lower their chances at getting over their problems? How gauche. We’d rather not mention all that. So tasteless”

There were a few response pieces, and surprise!!! – New York Magazine ran their own response, “Why Alcoholics Anonymous Works” which they linked to in their diss of Glaser’s article. They have the nerve to call Glaser’s article “bleary on the science”, while their not-so-brilliant takedown is a travesty.

Glaser mentions the prestigious Cochrane Review meta-analysis of 12 step programs in her case against AA:

Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works. In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

And this is the main point the NY Mag response hones in on, saying “Here and throughout the piece, Glaser is simply ignoring a decade’s worth of science.” How so? Is it the case that every study prior to 2006 shows that AA doesn’t work, yet every study after 2006 shows that it works? If that were true, wouldn’t it be extremely odd? Do they question the Cochrane Collaboration -note, NY Mag doesn’t question the credibility of Cochrane – indeed, they make their case by talking to researchers who now work beside the guy that did the Cochrane Review a decade ago and they eventually promise newer better Cochrane review will vindicate them. They ran Glaser’s article by him and a few other researchers, and they were incredulous. INCREDULOUS, so there you go. I guess Glaser is full of shit… or is she?

These researchers promise that there’s a bunch of new research that demonstrates AA’s effectiveness:

The data from these sorts of studies, argued Kelly, Kaskutas, and other researchers with whom I spoke, suggest that it [Twelve Step Facilitation, a counseling model based on the 12 steps] outperforms many alternatives. “They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.

Seems like a smoking gun of a takedown, right? But look at what is actually being said:

“a 10 to 20 percent advantage… in terms of days abstinent” and

“30 percent to 50 percent higher rates of continuous abstinence”

SO WHAT! “Days abstinent” and “continuous abstinence” are highly specific measures of success, and this is where it gets deep. First the Temperance Movement, and then Alcoholics Anonymous, are the ones who defined abstinence as the mark of success in dealing with drinking problems. They both are (and were, as it were) religious organizations who see drinking as sin, and thus to them abstinence is the only way to measure success. But think about it – is drinking in and of itself a problem, and is it the problem that people seek to address? NO.

The problems people have with drinking and that they seek to address is that they maybe drink too often and abandon other priorities to drinking, or that they drink too much when they drink and behave badly, causing problems in their life and social lives, or perhaps they have health problems created by or exacerbated by their continued heavy drinking. If not for such drinking-related problems – THERE WOULD BE NO REASON TO SEEK HELP AND CHANGE YOUR DRINKING.

Abstinence as the only acceptable change to be made in drinking then, should be seen as a complete and total non-sequitur here. To make the point clear (with an admittedly imperfect analogy), you don’t tell someone who’s overweight to swear off all food. That would just seem so extreme, left field, and out of the blue – you’d tell them to change their diet. And if those changes solved the problem of unwanted weight, then you’d consider them successful. We wouldn’t dismiss their weight loss because they were still eating.

We should see the demand for abstinence the same way. This isn’t to say it’s bad to abstain, or people shouldn’t abstain. It’s only to say that it isn’t the only way to address the drinking related problems that people want to solve. Less drinking per drinking occasion, or less drinking occasions are also choices that would address those problems. And if someone lessens their drinking in a way that puts an end to these drinking related problems in their life, would you categorize them as “successful” in addressing their drinking problem? I would.

12 step programs have higher binge drinking rates when compared to CBT. There’s another measure of success. Is that everything? No, but the point is there are several ways to measure success. Another way of measuring it is by whether people could still be classified as “alcoholic” or not according to diagnostic standards. The biggest and most recent epidemiological study that gauged this – called NESARC – found that roughly three quarters of people who had ever been “Alcohol Dependent” (officially alcoholic according to DSM-IV standards) at some point in their lives were no longer “Alcohol Dependent” in the past year. This held for both those who attended treatment and 12 step programs at some point – a minority of people – as well as for the much larger group of people who had never formally sought help. Treated or untreated, when it came to fitting the diagnosis of Alcohol Dependent, there was no difference (well, the untreated group fared 4 points better on this measure, but that might be chalked up to a margin of error).

Thus, most people were basically successful in NESARC, in terms of ending their alcohol dependence. What that means is that they could still be drinking to some degree, yet not be drinking in a way that’s causing major problems or classified as alcoholic. And in fact, that’s what many of them did. Depending on how you decide to parse the numbers, at least a HUGE portion of them, if not a majority also became moderate drinkers. But this is also where a big difference in the groups shows up, and it brings us back to the “new evidence” that supposedly debunks Glaser’s claims about AA’s effectiveness.

NESARC showed that more people who get formal help of any kind become abstinent – and more people who don’t get help become moderate. In numbers, 35.1% of those who got help became abstinent eventually, and 12.4% of those who didn’t seek help became abstinent (I’ve got a full breakdown of this study here – Substance Dependence Recovery Rates: With and Without Treatment). But the remainder of both groups that were neither dependent nor abstinent fell into some category of non-dependent – i.e. moderate drinking. Which meant that what the untreated group lacked in abstainers, they made up for with moderate drinkers – which are still successes in every meaningful way.

However, if you looked at this through the puritan abstinence lens – 35.1% vs 12.4% – you could easily make statements such as “treatment produced a success rate nearly three times higher than natural recovery” or that “your chances of recovery are decreased by two thirds without treatment” and you would be technically accurate in what you’ve said. The accuracy is in your definitions of “success” and “recovery.” When these represent abstinence, the treated groups fare better. But if success or recovery are defined as eliminating significant drinking related problems – then your presentation would be inaccurate.

And now is when you as the reader need to do some soul searching. How do you define success in addressing a substance use problem?

Do you have an abstinence fetish? Do you just think that drinking is sinful and must be sworn off altogether, or that people have somehow lost the right to drink once they’ve experienced problems with it? Do you not really care about the problems, and just care about eliminating alcohol use? If so, then those guys NY Mag talked to really blew Glaser out of the water from your point of view.

Or…do you believe in actually eliminating problems? Because if that’s your measure of success, those guys that NY Mag talked to didn’t do a damn thing to debunk Glaser’s case. They just discussed some abstinence statistics. Don’t get me wrong, abstinence statistics have a place and can be useful, but they alone don’t really tear down the bigger picture claims about the success of various approaches to dealing with substance use problems. Nor for that matter do some of the other measures raised in the article.They go on, quoting an email from the researchers they spoke with:

TSF is an empirically-supported treatment, showing clinical efficacy, and is likely to result also in lowered health care costs relative to alternative treatments that do not link patients with these freely available recovery peer support services.

Translation: it’s cheaper to dump people into support groups than to give them these other treatments.

Ok, I buy that. But guess what – measuring TSF (AA) relative to other treatments is still just measuring a variety of approaches that are literally no more successful than getting no treatment at all. So then if we’re just concerned with cost, then I’d say the zero cost no-treatment approach is the absolutely most cost effective approach. But now, we’re not really discussing success in terms of eliminating drinking related problems anymore, are we? And that is the sleight of hand that was pulled in New York Mag’s article that supposedly debunked the “bleary eyed science” in Gabrielle Glaser’s article in The Atlantic.

The data points mentioned in NY Mag are part of a claim that the next Cochrane report on AA will show it’s a successful evidence based treatment, as they said:

In other words, the most comprehensive piece of research Glaser is using to support her argument will, once it takes into account the latest findings, likely reverse itself.

Great. If it reverses itself based on what they presented in that article, then it’s not really telling those of us in the real non-puritanical, non-abstinence-fetishizing world anything about what really works to help people with their substance use problems.

Sorry if all of this quibbling about the realities of a system that affects millions of troubled people distasteful to you tastemakers over at New York Magazine, but AA doesn’t work, nor does the broader category of services known as “addiction treatment.” It is a problem that we believe that they do, and that we tell people they must become involved with this system and subculture or else they’ll die. I know it’s not a storyline on Girls, but I think it’s worth discussing.