Slate.com recently featured an article by Yale Psychiatry resident physician Arjune Rama in which he interviewed comedian Marc Maron (host of the populare WTF podcast) about addiction, titled What Marc Maron Taught Me About Addiction. However, it seemed more like Maron was interviewing the doctor:
Slate: A big problem for psychiatrists when it comes to understanding addiction is that there are many of us who have no experience with it on a personal level. So sometimes there’s a built-in disconnect between the treater and the patient.
Maron: Well, yeah, because you guys are just taught to medicate and suggest things. [Pauses.] Have you even read The Big Book?
Slate: No…
Maron: Why not?!
Slate: I know, I should… I treat people who swear by it and I haven’t even looked at it.
Maron: Yeah, see, that’s the thing with all you guys. Most therapists have never read that fucking book. But you send people to A.A. meetings, don’t you?
Slate: I do.
And there’s the big slip up. Rama admits that although he’s never read the Big Book – i.e., he doesn’t really know what’s taught in Alcoholics Anonymous – he still sends people to AA meetings. Apparently his colleagues don’t see any problem with this either, as one of them tweeted at him, regarding the article:
“Good advice?” Is it good advice to send troubled people to an underground organization whose tenets you know nothing about? A license to practice medicine confers instant reputation and credibility upon these people. We know all too well that people will do almost anything they’re told by a doctor from Yale – remember that whole Milgram electroshock experiment? Doctors hold great persuasive power, and yet they’ll readily tell people that they should go to 12 step meetings without ever having done the least bit of investigation into its real world consequences.
If Dr Rama hasn’t even taken a peek at the Big Book of Alcoholics Anonymous, then chances are he also hasn’t looked into any of the research on AA and adherence to its tenets. After all, he’s recommending that people go to AA, so he must not know that:
After a year of exposure to AA, alcoholics become 9 times more likely to binge drink than those attending a CBT based support group, and 5 times more likely to binge drink than those who received no formal help: AA leads to binge drinking.
Alcoholics Anonymous attendance doesn’t increase success rates for alcoholics: See Vaillant study in How Effective is AA and 12-Step Treatment.
More people resolve their drinking problems without AA than with it. Furthermore, the longer term prognosis is better for those who never were exposed to 12-step programs. That is, in those who seek help (80% of whom receive 12-step help), 20 years after onset of alcohol dependence, they are more than three times more likely to still be dependent on alcohol as compared to those alcoholics who never received help: Substance Dependence Recovery Rates With and Without Treatment.
Need I go on? There is research that shows AA to be harmful, and there is research which shows it to be less effective than getting no help at all, and there is research which shows it be a wash. At best, a licensed doctor recommending AA is like a licensed doctor recommending homeopathic remedies. At worst, it’s like a licensed doctor recommending poison. At least homeopathic remedies don’t require that you spend an hour a day building intimate relationships with a group of deeply troubled strangers, who may include rapists and criminals.
And what exactly did the doctor learn from Marc Maron?
Slate: If you could talk to a clinician-in-training about how they can better help people suffering from addiction, what would you say?
Maron: [Long pause.] I would tell them to think about addiction the same way I tell alcoholics: “You’re going to die from this. Nobody survives this. One way or the other, it’s going to kill you. It may take a while, or it may happen in one night for a million different reasons—a bad mix of drugs, drunk driving, catching a bullet because you’re scoring drugs in a shitty place, whatever. There’s a million ways it can kill you—but it will kill you. Even if you’re 65—sure, you’ve made it that far, but then your liver goes bad. I know guys who haven’t shot dope in 20 years but now they’ve got Hep C. You’re dealing with a chronic condition. And it’s going to kill you.” That’s what I would tell them.
“You’re going to die from this.” That’s the big takeaway from the article. It wasn’t lost on a Psychiatry Student Interest Group following the doctor:
But it simply isn’t true. As the link I posted above shows, most people get over their addictions, and they usually do it without the gloom and doom predictions of 12-step programs. If the doctor did any research, he would know that AA teaches this (“jails, institutions, and death”), and he would also know it isn’t true. But then, he might also realize that this kind of talk, besides being untrue, clashes with some of the most well supported discoveries of modern psychology.
According to research done by Carol S Dweck, Albert Bandura, and Martin Seligman, among others, into Attribution, Explanatory Style, Self-Efficacy, Implicit Theories, and Locus of Control – believing that you’re going to ultimately fail, that you are incapable of change, and that your troubles are due to unchangeable traits of your very being – is a surefire way to become depressed, give up, and fail. There are MOUNTAINS of evidence backing this up. Yet, this is exactly what 12-step programs teach people, and it trains them through repetition to develop self-talk that reinforces it.
In light of all this, is it sound practice for doctors to recommend that people go to 12-step meetings? Especially while they’re completely uninformed about what goes on there? In my opinion, not only is it unsound practice, it’s probably malpractice.
I saw that article too. It’s quite astonishing. Why do we as a culture have such a different set of standards for “addiction” than we do for other areas of medicine?
Notice too that the interviewer makes the same somewhat logical assumption that our whole society seems to be making: there must be something to this AA thing, right? I mean, how could there not be when it’s everywhere? But once you do some digging you see that it is actually quite possible that AA can both be everywhere and be a net negative. Marc Maron does not have special insights to “addiction.” It’s worse than that. He has learned exactly the wrong lessons.
Great point Jonas. That really is the problem. There is an assumption, but it’s not logical. There’s even a name for it as a logical fallacy: Appeal to Common Practice – or Appeal To Tradition. It’s exactly what you described: everyone is doing it, so it must make sense.
There’s another thing you said, that I plan on stealing. You used the phrasing “net negative.” I’ve really tried to communicate that in other ways, but the point is usually missed. I think people perceive that I’m trying to deny that they enjoyed their 12-step experience and found it helpful. I’m sure you know this isn’t my objective or belief. However, I do see 12-step programs as a “net negative” – yes, there are some people who find it helpful, but on a whole, when you look at all of the people who are mislead by it, and end up feeling more hopeless and helpless, it does more harm than good.
However, I reject the overly diplomatic approach of saying “different things work for different people” or “AA isn’t for everyone”, because I think the people who find it helpful, actually helped themselves in spite of the negative things taught by AA. I don’t want to burst their bubble, but I also don’t want to give it any stamp of approval or credit for “causing” people to get over their problems, because that might encourage others to try it. Once they try it, their chances of success are reduced.
Basically, I wish that the people who love AA wouldn’t visit this site. They needn’t look behind the curtain. I don’t want to fight with them. I just want to direct people who haven’t gone down that path yet, or those who have with disastrous results, toward different ideas that can be more helpful, and not harmful.
I think saying it’s a net negative is a better way to get this across.
Feel free to steal it, Steve. I think “net negative” is perhaps a succinct way to say that AA isn’t all it’s cracked up to be without sounding like you’re attacking everyone who has been helped by AA.
Another thing I’m trying to form a way to say is something like “It’s not that it doesn’t work for anyone, but it’s a terrible public health policy, and it’s pretty much the policy we have right now.”