The Clinician’s Illusion In Addiction and Recovery

Is it really true that the only way to end an addiction is by getting several rounds of medical addiction treatment or devoting the rest of your life to a 12-step program? The answer is an unequivocal no. The best research available shows that only one-quarter of the people who successfully overcome an alcohol use problem actually attend such programs. This leaves us with 75% who overcome such problems without ever seeking professional help or stepping foot in an Alcoholics Anonymous meeting (see Substance Dependence Recovery Rates With and Without Treatment).

Why then do so many AA members and addiction counselors insist that an alcoholic will be doomed without treatment or AA? 12-steppers and professional counselors alike are both fond of saying that without their solutions people are doomed to “jails, institutions, or death.” Some would say that the counselors who make such claims are simply lying because they want more business. And many would say that the AA members who make such claims are simply brainwashed followers looking to drag others into their cult. While these are possibilities (and perhaps true in some cases) I’m not so quick to imply such dubious intentions. There is another explanation for such misinformation: an honest error of judgment known as The Clinician’s Illusion.

The Clinician’s Illusion is a sort of bias error in which a person who works with a troubled or unhealthy population develops a distorted perception of a phenomenon based on the cases they deal with.  Here’s an excerpt from the original paper on the subject:

Imagine a clinician viewing persons with one of these illnesses as they appear in the current case load, say, on ward rounds on a given day. The probability of encountering a given patient on this day will be proportional to the duration of this patient’s illness. A patient whose illness lasts a year is far more likely to appear on any given day than one whose illness lasts only two months, in fact, six times more likely; and a patient whose illness lasts for ten years is ten times more likely to appear than one whose illness lasts only one year. For this example, each of the few patients making up the 2% of the population of longest duration (X = 128) is 64 times more likely to appear than each of the 40% of shortest duration (X = 2), 32 times more likely to appear than each of the 25% of next shortest duration (X 4), and so on.

For example, take an addiction counselor, and all the clients they work with – we’ll consider one with 10 clients. They may see 5 cases who breeze in and out of rehab quickly, using only 4 hours of the counselors time each – adding up to a total of 20 hours. But the other 5 who struggle and spend 6 months in rehab between extended stays and return visits use up 24 hours worth of counseling each. This group of 5 clients take up a total of 120 counseling hours. 20 vs 120 – obviously the tough cases or “chronic relapsers” (as the recovery culture calls them) will naturally make the biggest impression upon the counselor – thus distorting their view of the nature of addiction and recovery.

Now the above is simply a hypothetical which may or may not be the experience of various addiction counselors, but more importantly there is a verifiably true circumstance which most counselors are totally unaware of: for every 1 client who does well after a course of treatment there are at approximately 3 more who overcame their addictions with absolutely no time in rehab or meetings (see Substance Dependence Recovery Rates With and Without Treatment).. The counselor’s experience is that they’ve only been seeing people get well with treatment – they didn’t see the others, because those others didn’t come to their rehab!

So when a counselor says that you can’t quit without treatment, they’re expressing an honest opinion based on their unique perspective and place in life. Nevertheless, they’re wrong, because their opinion is based on a limited sample of people who have substance use problems.

Likewise – the AA sponsor who proclaims that you must attend AA meetings to quit a drinking problem is also expressing an honest yet faulty opinion. They have little chance to see someone quit drinking without AA because if they run into a problem drinker, they’ll drag them to a meeting. Most of the people they know who have quit, are also in AA with them. And should they run into someone who has previously quit, and done so without AA, that person will likely hide their status as a former problem drinker so as to avoid being proselytized or badgered by the AA member. Thus, we have the perfect storm of a bias error – another form of The Clinician’s Illusion is alive and well with AA members (even though most are not technically “clinicians”).

Of course, there are many other complex factors which contribute to the erroneous views that “AA is the only way”, “addiction is a treatable disease”, “relapse is a part of recovery”, and “longer episodes of treatment are more effective”, but they’re too numerous to explore here.  Just remember, there is reliable evidence that 3 times as many people overcome substance use problems without treatment or meetings – yet people continue to claim that it’s impossible to recover without following such methods.  The ubiquity of such claims is most likely due to the Clinician’s Illusion.

Despite being identified some 3 decades ago, The Clinician’s Illusion continues to taint the ruling opinions about addictions, recovery, and treatment.  Researchers, who should be less vulnerable to the illusion, simply seem to assume that treatment is the only way, and almost never include an untreated control group in their studies of addiction.  They generally only compare groups of addicts exposed to different treatments, declare one method a success, and thus further various myths and misinformation about addiction.  But as long as they refuse to consider the vast majority of addicts and alcoholics who solve their problems outside of the conventional recovery culture, then we’ll all fall victim to The Clinician’s Illusion (unless we’re vigilant about taking such information with a grain of salt).

Citation: Archives of General Psychiatry. 1984 Dec;41(12):1178-82.  The clinician’s illusion.  Cohen P, Cohen J.  Link at NCBI