Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective.
By the time he was a practicing defense attorney, J.G. (who asked to be identified only by his initials) sometimes drank almost a liter of Jameson in a day. He often started drinking after his first morning court appearance, and he says he would have loved to drink even more, had his schedule allowed it. He defended clients who had been charged with driving while intoxicated, and he bought his own Breathalyzer to avoid landing in court on drunk-driving charges himself.
Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.
J.G.’s despair was only heightened by his seeming lack of options. “Every person I spoke with told me there was no other way,” he says.
Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”
Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy. It offers a single path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their ego, accept that they are “powerless” over booze, make amends to those they’ve wronged, and pray.
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.”
The Big Book includes an assertion first made in the second edition, which was published in 1955: that AA has worked for 75 percent of people who have gone to meetings and “really tried.” It says that 50 percent got sober right away, and another 25 percent struggled for a while but eventually recovered. According to AA, these figures are based on members’ experiences.
In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.
The first night, I took a pill at 6:30. An hour later, I sipped a glass of wine and felt almost nothing—no calming effect, none of the warm contentment that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it. I had never found wine so uninteresting. Was this a placebo effect? Possibly. But so it went. On the third night, at a restaurant where my husband and I split a bottle of wine, the waitress came to refill his glass twice; mine, not once. That had never happened before, except when I was pregnant. At the end of 10 days, I found I no longer looked forward to a glass of wine with dinner. (Interestingly, I also found myself feeling full much quicker than normal, and I lost two pounds. In Europe, an opioid antagonist is being tested on binge eaters.)
In 1934, just after Prohibition’s repeal, a failed stockbroker named Bill Wilson staggered into a Manhattan hospital. Wilson was known to drink two quarts of whiskey a day, a habit he’d attempted to kick many times. He was given the hallucinogen belladonna, an experimental treatment for addictions, and from his hospital bed he called out to God to loosen alcohol’s grip. He reported seeing a flash of light and feeling a serenity he had never before experienced. He quit booze for good. The next year, he co-founded Alcoholics Anonymous. He based its principles on the beliefs of the evangelical Oxford Group, which taught that people were sinners who, through confession and God’s help, could right their paths.
Tom McLellan, a psychology professor at the University of Pennsylvania School of Medicine who has served as a deputy U.S. drug czar and is an adviser to the World Health Organization, says that while AA and other programs that focus on behavioral change have value, they don’t address what we now know about the biology of drinking.
Alcohol acts on many parts of the brain, making it in some ways more complex than drugs like cocaine and heroin, which target just one area of the brain. Among other effects, alcohol increases the amount of GABA (gamma-aminobutyric acid), a chemical that slows down activity in the nervous system, and decreases the flow of glutamate, which activates the nervous system. (This is why drinking can make you relax, shed inhibitions, and forget your worries.) Alcohol also prompts the brain to release dopamine, a chemical associated with pleasure.
People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden’s founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other … This led to a heartening discovery, one that’s become a cornerstone of the Minnesota Model: Alcoholics and addicts can help each other.
That may be heartening, but it’s not science. As the rehab industry began expanding in the 1970s, its profit motives dovetailed nicely with AA’s view that counseling could be delivered by people who had themselves struggled with addiction, rather than by highly trained (and highly paid) doctors and mental-health professionals. No other area of medicine or counseling makes such allowances.
There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever—not even a GED or an introductory training course was necessary—and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery.
Mark Willenbring, the St. Paul psychiatrist, winced when I mentioned this. “What’s wrong,” he asked me rhetorically, “with people with no qualifications or talents—other than being recovering alcoholics—being licensed as professionals with decision-making authority over whether you are imprisoned or lose your medical license?
“The history—and current state—is really, really dismal,” Willenbring said.
Perhaps even worse is the pace of research on drugs to treat alcohol-use disorder. The FDA has approved just three: Antabuse, the drug that induces nausea and dizziness when taken with alcohol; acamprosate, which has been shown to be helpful in quelling cravings; and naltrexone. (There is also Vivitrol, the injectable form of naltrexone.)
Reid K. Hester, a psychologist and the director of research at Behavior Therapy Associates, an organization of psychologists in Albuquerque, says there has long been resistance in the United States to the idea that alcohol-use disorder can be treated with drugs. For a brief period, DuPont, which held the patent for naltrexone when the FDA approved it for alcohol-abuse treatment in 1994, paid Hester to speak about the drug at medical conferences. “The reaction was always ‘How can you be giving alcoholics drugs?’ ” he recalls.
Hester says this attitude dates to the 1950s and ’60s, when psychiatrists regularly prescribed heavy drinkers Valium and other sedatives with great potential for abuse. Many patients wound up dependent on both booze and benzodiazepines. “They’d look at me like I was promoting Valley of the Dolls 2.0,” Hester says.
There has been some progress: the Hazelden center began prescribing naltrexone and acamprosate to patients in 2003. But this makes Hazelden a pioneer among rehab centers. “Everyone has a bias,” Marvin Seppala, the chief medical officer, told me. “I honestly thought AA was the only way anyone could ever get sober, but I learned that I was wrong.”
Stephanie O’Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol-use disorder for more than two decades, says naltrexone’s limited use is “baffling.”
“There was never any campaign for this medication that said, ‘Ask your doctor,’ ” she says. “There was never any attempt to reach consumers.” Few doctors accepted that it was possible to treat alcohol-use disorder with a pill. And now that naltrexone is available in an inexpensive generic form, pharmaceutical companies have little incentive to promote it.
In one recent study, O’Malley found naltrexone to be effective in limiting consumption among college-age drinkers. The drug helped subjects keep from going over the legal threshold for intoxication, a blood alcohol content of 0.08 percent. Naltrexone is not a silver bullet, though. We don’t yet know for whom it works best. Other drugs could help fill in the gaps. O’Malley and other researchers have found, for example, that the smoking-cessation medication varenicline has shown promise in reducing drinking. So, too, have topirimate, a seizure medication, and baclofen, a muscle relaxant. “Some of these drugs should be considered in primary-care offices,” O’Malley says. “And they’re just not.”
In late August, I visited Alltyr, a clinic that Willenbring founded in St. Paul. It was here that J.G. finally found help.
After his stays in rehab, J.G. kept searching for alternatives to 12-step programs. He read about baclofen and how it might ease both anxiety and cravings for alcohol, but his doctor wouldn’t prescribe it. In his desperation, J.G. turned to a Chicago psychiatrist who wrote him a prescription for baclofen without ever meeting him in person and eventually had his license suspended. Then, in late 2013, J.G.’s wife came across Alltyr’s Web site and discovered, 20 minutes from his law office, a nationally known expert in treating alcohol- and substance-use disorders.
J.G. now sees Willenbring once every 12 weeks. During those sessions, Willenbring checks on J.G.’s sleep patterns and refills his prescription for baclofen (Willenbring was familiar with the studies on baclofen and alcohol, and agreed it was a viable treatment option), and occasionally prescribes Valium for his anxiety. J.G. doesn’t drink at all these days, though he doesn’t rule out the possibility of having a beer every now and then in the future.
I also talked with another Alltyr patient, Jean, a Minnesota floral designer in her late 50s who at the time was seeing Willenbring three or four times a month but has since cut back to once every few months. “I actually look forward to going,” she told me. At age 50, Jean (who asked to be identified by her middle name) went through a difficult move and a career change, and she began soothing her regrets with a bottle of red wine a day. When Jean confessed her habit to her doctor last year, she was referred to an addiction counselor. At the end of the first session, the counselor gave Jean a diagnosis: “You’re a drunk,” he told her, and suggested she attend AA.
The whole idea made Jean uncomfortable. How did people get better by recounting the worst moments of their lives to strangers? Still, she went. Each member’s story seemed worse than the last: One man had crashed his car into a telephone pole. Another described his abusive blackouts. One woman carried the guilt of having a child with fetal alcohol syndrome. “Everybody talked about their ‘alcoholic brain’ and how their ‘disease’ made them act,” Jean told me. She couldn’t relate. She didn’t believe her affection for pinot noir was a disease, and she bristled at the lines people read from the Big Book: “We thought we could find a softer, easier way,” they recited. “But we could not.”
Surely, Jean thought, modern medicine had to offer a more current form of help.
Then she found Willenbring. During her sessions with him, she talks about troubling memories that she believes helped ratchet up her drinking. She has occasionally had a drink; Willenbring calls this “research,” not “a relapse.” “There’s no belittling, no labels, no judgment, no book to carry around, no taking away your ‘medal,’ ” Jean says, a reference to the chips that AA members earn when they reach certain sobriety milestones.
In his treatment, Willenbring uses a mix of behavioral approaches and medication. Moderate drinking is not a possibility for every patient, and he weighs many factors when deciding whether to recommend lifelong abstinence. He is unlikely to consider moderation as a goal for patients with severe alcohol-use disorder. (According to the DSM‑5, patients in the severe range have six or more symptoms of the disorder, such as frequently drinking more than intended, increased tolerance, unsuccessful attempts to cut back, cravings, missing obligations due to drinking, and continuing to drink despite negative personal or social consequences.) Nor is he apt to suggest moderation for patients who have mood, anxiety, or personality disorders; chronic pain; or a lack of social support. “We can provide treatment based on the stage where patients are,” Willenbring said. It’s a radical departure from issuing the same prescription to everyone.
The difficulty of determining which patients are good candidates for moderation is an important cautionary note. But promoting abstinence as the only valid goal of treatment likely deters people with mild or moderate alcohol-use disorder from seeking help. The prospect of never taking another sip is daunting, to say the least. It comes with social costs and may even be worse for one’s health than moderate drinking: research has found that having a drink or two a day could reduce the risk of heart disease, dementia, and diabetes.
To many, though, the idea of non-abstinent recovery is anathema.
No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence. Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.
In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.” Not everyone saw it that way. In 1982, abstinence-only proponents attacked the Sobells in the journal Science; one of the writers, a UCLA psychologist named Irving Maltzman, later accused them of faking their results. The Science article received widespread attention, including a story in The New York Times and a segment on 60 Minutes.
Over the next several years, four panels of investigators in the United States and Canada cleared the couple of the accusations. Their studies were accurate. But the exonerations had scant impact, Mark Sobell said: “Maybe a paragraph on page 14” of the newspaper.
The late G. Alan Marlatt, a respected addiction researcher at the University of Washington, commented on the controversy in a 1983 article in American Psychologist. “Despite the fact that the basic tenets of [AA’s] disease model have yet to be verified scientifically,” Marlatt wrote, “advocates of the disease model continue to insist that alcoholism is a unitary disorder, a progressive disease that can only be arrested temporarily by total abstention.”
What’s stunning, 32 years later, is how little has changed.
The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic. Like Willenbring in Minnesota, they are among a small number of researchers and clinicians, mostly in large cities, who help some patients learn to drink in moderation.
“We cling to this one-size-fits-all theory even when a person has a small problem,” Mark Sobell told me. “The idea is ‘Well, this may be the person you are now, but this is where this is going, and there’s only one way to fix it.’ ” Sobell paused. “But we have 50 years of research saying that, chances are, that’s not the way it’s going. We can change the course.”
During my visit to Finland, I interviewed P., a former Contral Clinic patient who asked me to use only his last initial in order to protect his privacy. He told me that for years he had drunk to excess, sometimes having as many as 20 drinks at a time. A 38-year-old doctor and university researcher, he describes himself as mild-mannered while sober. When drunk, though, “it was as if some primitive human took over.”
His wife found a Contral Clinic online, and P. agreed to go. From his first dose of naltrexone, he felt different—in control of his consumption for the first time. P. plans to use naltrexone for the rest of his life. He drinks two, maybe three, times a month. By American standards, these episodes count as binges, since he sometimes downs more than five drinks in one sitting. But that’s a steep decline from the 80 drinks a month he consumed before he began the treatment—and in Finnish eyes, it’s a success.
Sari Castrén, the psychologist I met at Contral, says such trajectories are the rule among her patients. “Helping them find this path is so rewarding,” she says. “This is a softer way to look at addiction. It doesn’t have to be so black and white.”
J.G. agrees. He feels much more confident and stable, he says, than he did when he was drinking. He has successfully drunk in moderation on occasion, without any loss of control or desire to consume more the next day. But for the time being, he’s content not drinking. “It feels like a big risk,” he says. And he has more at stake now—his daughter was born in June 2013, about six months before he found Willenbring.
Could the Affordable Care Act’s expansion of coverage prompt us to rethink how we treat alcohol-use disorder? That remains to be seen. The Department of Health and Human Services, the primary administrator of the act, is currently evaluating treatments. But the legislation does not specify a process for deciding which methods should be approved, so states and insurance companies are setting their own rules. How they’ll make those decisions is a matter of ongoing discussion.
Still, many leaders in the field are hopeful—including Tom McLellan, the University of Pennsylvania psychologist. His optimism is particularly poignant: in 2008, he lost a son to a drug overdose. “If I didn’t know what to do for my kid, when I know this stuff and am surrounded by experts, how the hell is a schoolteacher or a construction worker going to know?” he asks. Americans need to demand better, McLellan says, just as they did with breast cancer, HIV, and mental illness. “This is going to be a mandated benefit, and insurance companies are going to want to pay for things that work,” he says. “Change is within reach.”