by Joshua Hoe
Sorry, I have been a bit sparse on posting lately. With this site, I would rather not post until I have something I feel very confident about. I take recovery and addiction very seriously, and while I always reveal that I am not an expert, I do want to make sure I am careful and inspired about whatever I post.
This is my third post tangentially about Maia Szalavitz book Unbroken Brain. To be 100%, I have only just started reading the book. However, Ms. Szalavitz has published a large number of articles about the book and I have had a few Twitter exchanges with her about her take on 12-step programs.
During our last exchange, she forwarded me a few links to articles that she has written about 12-step program, so this is really more a response to those articles than it is to her book.
Let me preface this by saying that I identify myself with no particular program, my opinions are my own, and I do not speak for any 12-Step program.
12-Step Programs As Treatment
Here is the last interaction that I had with Ms. Szalavitz:
So let’s dive into what she says in those two articles.
First, in her article in the Influence she suggests that she embraces, if critically, many of the ideas of the program from becoming part of the community, to hearing and sharing stories, and even to faith. I agree with everything she says here, including her being sometimes uncomfortable with how “faith” is deployed to many of the program steps being a starters kit for CBT (Cognitive Behavioral Therapy).
To her list I would also add that following a 12-step program is a basic course in establishing intimacy (not sex) between adult human beings. 12 Step programs, when followed, teach you to speak about your problems and feelings in the ways addicts often resist.
I have also already mentioned that I mostly agree with her description of addiction as a kind of learning disorder. That addiction develops by learning to respond to the triggering moments in our lives incorrectly. If you read either of our books, you will read much more about our similar if slightly different takes on this.
So, if we agree about all of this, what are Ms. Szalavitz problems with 12 Step Programs? Let’s now turn to the second article she suggested for me to read.
Higher Powers and Moral Failures
Ms Szalavitz says:
“…AA’s reliance on a higher power, confession, prayer and proselytizing is so unlike treatment for other medical or psychological disorders that its predominance seems to call into question whether addiction is a disease at all. I believe that addiction is a medical problem. I view addiction as a developmental disorder, which is a position supported by research. And while I don’t have any objection to 12-step programs as self-help, I do think it’s impossible to destigmatize addiction while also rendering it the only diagnosis in medicine for which the treatment is explicitly moral.”
In other articles of hers I have read she also says that one of the primary problems most non-addicted Americans face in accepting that Addiction is a disease is that they have heard for years that it is a moral failing. In other words, 12-step programs have been spreading the gospel that addiction is a moral failing for years and this gospel is a roadblock to the idea that addiction is a disease (to be treated medically).
I will admit, this does trouble me and it is one of my primary problems with 12-step programs as well.
I have suggested in other writing on this subject that I believe what was intended by the “moral defects” language was actually a connection to original sin. In other words, all human beings have moral defects and those defects are what emotionally connect us all. The notion that we are all united by sin and the desire to become better than what we are.
Unfortunately, there is no “legislative history” that I can find that explains the founders “Big Book” intent. It is certainly true that a large number of people in the program practice and proselytize that addiction is, in fact, a moral failing. I have heard conference tapes of people encouraging sponsors to “fire” sponsees that don’t measure up etc.
Most upsetting to me is how much self-loathing happens in the spaces created by the acceptance of “moral failure” and “defects of character.” For those of you familiar with “S” programs you are probably aware that one of the major controversies in “S” programs is the idea that same-sex relationships are often not allowed within sobriety definitions.
I tend to feel that the overall value of the program is so great that we should all work on reform of the program (and remember that many of its practices are dated and possibly cruel). I also try to emphasize readings of the texts that do not suggest we should feel shame when we struggle with recovery.
I have written many defenses of 12-Step ideology in general, but not about this “shame” aspect.
I also freely realize that this message puts me at odds with many of the hard-core rank and file supporters of 12-Step methods.
Treatment Vs. Support
Ms. Szalavitz continues:
“In fact, I would argue, the 12-step approach would be dismissed outright were it proposed as treatment for disorders such as depression, heart disease or schizophrenia. Until we recognize the discrepancy, I’m skeptical that we’ll make substantial progress in treating addiction.”
I have some disagreements with her here. First, remember during the first article, she explained that following the 12-steps is very similar and maybe a starters guide to practicing Cognitive Behavioral Therapy. I agree.
Psychological treatment is also, to a great extent, about getting people to talk about the things that they keep deep inside and to become comfortable with appropriately expressing feelings (especially sadness).
In addition, as someone who struggles with generalized depression and panic disorder, I would like to suggest that the treatment for addiction should probably not be much like the treatment for “heart disease.”
Therapeutic treatment is rarely entirely similar to physical medical procedures. There is a reason why diagnosis of most mental or emotional conditions comes with a recommendation for visiting both a psychiatrist (drugs) and psychologist (therapy).
I do believe she is, to some extent, correct that 12-step methods should rarely be seen as the only or even the main “treatment” for addiction.
As I have said many times can be many components to a good program of recovery:
* Therapy – Helps people get to the root of their original trauma and find out the “Why” answers offers successful tools like CBT
* Psychiatry – Helps people balance their dopamine, medically cope with withdrawal symptoms, or respond to triggers medically
* 12-Steps – Helps people find community, learn coping mechanisms for triggers, talk about what triggers them and how they feel, and helps people learn intimacy skills
* Faith – Helps people find purpose and community, learn coping mechanisms for triggers, and helps deal with existential fears
* Tools and Relapse Prevention – Having additional tools available like family members who understand your situation or knowing you can go to the gym when triggered to get some endorphins pumping can also be very helpful
The more tools you have in the toolbox the better, in my humble opinion.
Ms. Szalavitz also has problems with the “professional” practice of the 12-step method. I agree entirely here. An entire industry grew up around the 12-step method and it is a core part of most relapse approaches. The problem is not that 12-step methods cannot help people in crisis, it is that they are not designed to be commercial in the first place.
It is troubling to have people forced to embrace faith-based methods as part of drying out. It is odd to see people pay large amounts of money to be forced into a program that should be free and non-professional.
Maia Szalavitz is also 100% correct to suggest that there is something really strange about a Doctor being involved in evaluating your spiritual relationship with a higher power. Or for that relationship to be part of a medical evaluation.
Jails, Institutions, or Death
Ms. Szalavitz continues:
“…as an AA slogan has it, is “jails, institutions or death,” is mainstream medicine. And this remains the case, even though courts that have entertained the question of whether mandating 12-step participation via the legal system violates the First Amendment separation of church and state have determined that it does. Of course, some argue, so long as the 12-step approach works, who cares? One problem is that 12-step groups only seem to help a minority of people who find them amenable. According to a researcher who has studied the groups for years, 70 percent of people who start drop out within six months. And, when compared head-to-head with cognitive behavioral therapy and motivational enhancement therapy, 12-step approaches do no better.”
As someone whose addiction took them to prison, I feel uniquely qualified to respond to this criticism (if you have read this blog for long you know I have been responding to this one for a long time).
First, 12-step programs do not promise that everyone recovers or even that a majority of people recover using the 12-step method. 12-Step orthodoxy is that “rarely have we seen a person fail who has thoroughly followed our path.” This implies much more than attending meetings. My guess is that less than 30% of attendees go to regular meetings, have a sponsor, and officially ‘work the steps.’
Working the steps is a very specific and formal process that is a TON of hard work. It is not just reading the steps and thinking about them. I guess what I am saying is that it is no surprise that the overall program recovery rate is 30% or less.
Second, 12-Step programs aren’t mutually exclusive with CBT or other forms of therapy (I know this because I have done exhaustive CBT myself). Ms. Szalavitz suggests that many people argue that the 12-Step method is the “only” method and that the 12-Step method discourages the use of drugs and other therapies.
While I certainly know people in 12-Step programs who have said things like this, the discouraging of therapy and treatment in 12-steps meetings has not accorded with my experience at all. I find that building a comprehensive program of recovery (filling a big tool box) is the best hope for recovery.
In virtually every meeting I have ever been a part of the majority of people at the meeting are either currently in or have been involved in therapy as well.
I have certainly had discussions with people who believe that using methadone or alcohol inhibitors is somehow cheating but who cares. Find the program that you can work. Be as sober as you can become.
Third, and perhaps most important, as Ms. Szalavitz herself mentions, none of the treatment methods have a massive success rate.
Recovery isn’t a competition between brands, lives are on the line. Find what works best for you and keep getting better. If using several methods works, use several methods. Be a borrower, discount the parts of the 12-Step method that work for you and discard the rest on your way from your meeting to your therapy appointment or to fill your prescription for naltrexone.
Anyway, at the end of the day, I think reading Ms. Szalavitz work can be part of your toolbox of recovery. She has some really persuasive and powerful things to say about addiction. I suspect our disagreements are much smaller than our areas of agreement.
Here is a link to her book:
And here is a link to my book:
What did you think of Maia Szalavitz arguments? Let me know, leave a comment!