Abstract
Lance Dodes has distinguished himself as one of the few recent contemporary psychoanalysts to apply his analytic and psychiatric training to exploring and explaining in depth what makes addictive behavior so compelling. His contributions have until now been valuable and well received. Particularly so has been his theory that addiction is at root motivated by feelings of helplessness and powerlessness, and that the repetitious features of addictive behavior are displaced attempts to deal with the rage such feelings engender; his conclusion is that addictions have all the characteristics of compulsive disorders and thus lend themselves to psychodynamic examination and treatment (Dodes 1996).
Given his valuable contributions to addiction studies, then, it is unfortunate that The Sober Truth, which Dodes has written with his son Zachary, a freelance writer, is so polemical in attacking Alcoholics Anonymous that it risks polarizing clinical psychodynamic approaches and twelve-step programs. Their arguments against twelve-step groups seem in fact a gift to hopeful debunkers of psychodynamic psychiatry, who would use the same tactics to discredit our work. Indeed, the Dodeses are so polemical that they are likely to alienate a group of potentially enthusiastic patients, students, and clinicians who might otherwise enrich our understanding and treatment of addiction.
The book has already drawn serious criticism from the community of addiction treatment providers. John F. Kelly and Gene Beresin, colleagues of Dodes at Harvard Medical School, for example, write the following on the website of Boston’s National Public Radio station: “Dr. Dodes’ book and comments are so far off the track of scientific research that he doesn’t realize that for the past several years, the addiction research field has moved beyond asking whether AA and 12-step treatment works, to investigating how and why they work.” Richard A. Friedman, Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medical College, writes in his thorough review in the New York Times (May 6, 2014) that “those looking for a scientifically accurate and nuanced understanding of addiction and its treatment will not find it in this book.”
Anyone with even cursory personal knowledge of twelve-step programs understands that they consider anonymity to be of the greatest importance. Thus, research on Alcoholics Anonymous presents the same challenges as research on psychotherapy. Adherence to anonymity has both protected these programs and their members, providing a well-bounded environment within which the work of recovery from addiction may occur. This anonymity is analogous to the psychoanalytic practice of confidentiality, which both protects our work and has the unfortunate consequence of rendering inapplicable the usual methods of quantitative study. That the tools of research may be inadequate to demonstrate the effectiveness of either twelve-step programs or psychoanalysis neither diminishes nor depreciates the value and utility of either path to recovery. As our empirically minded colleagues remind us, the absence of evidence is not evidence of absence.
Ironically, the only reliable statistic we could find in the Dodeses’ book is that over five million people recite the Serenity Prayer together at twelve-step meetings every year. That indicates a vast number of low-cost treatment hours, and countless numbers of alcoholics and their medical helpers testify to the benefits of the program. Would that psychoanalytic psychotherapy were so publicly affirmed!
The depiction of the “AA monopoly,” with very few changes, could easily be a description of psychoanalysis in the days before other forms of psychotherapy entered the market. Yet psychoanalysis has had an enormous impact on the evolution of other psychotherapies, just as twelve-step groups have had an important role in the development of alternative mutual support groups such as Rational Recovery and SMART Recovery, which share a similar underlying structure and process despite their many superficial differences.
Chapter 3 of the book, “Does AA Work?” contains the heart of the authors’ pseudostatistical polemic. They create a black-and-white straw man: “This conversation begins with a consideration of the difference between good science and bad science” (p. 29). Their first criticism of AA is the lack of a control group that would allow a “controlled study in which people are randomly assigned to respective groups” (p. 31). Questions of how people could be prevented from attending twelve-step groups, even if not assigned to them, or how they could be forced to attend them if assigned but unwilling, parallel the difficulty of eliminating “selection bias” in the study of psychoanalysis. The authors invoke this “compliance effect” to discredit twelve-step programs: “people who do things faithfully and regularly for their own well-being . . . are, in fact, fundamentally different from people who don’t” (p. 32).
These black-and-white arguments continue with their questioning of what constitutes success in recovery. They naively claim that “disease is usually a binary system; either you’ve got it or you don’t” (p. 34). They thus tacitly ignore or exclude diseases such as diabetes, hypertension, and even cancer, which like addiction and mental illness vary greatly in severity, chronicity, and natural history.
The authors complain about the sampling error of drawing conclusions from the testimony of people who have succeeded in becoming sober through AA. Yet later in the book they commit this sampling error themselves, using data from an online survey devised expressly for the purpose of criticizing AA. Such a method may work to gather opinions, but it is just bad science to look randomly for condemnatory opinions from the general populace on any topic, from psychoanalysis to toothpaste.
Chapter 1, “The Problem,” includes a section headed “Walking the Twelve Steps.” Here the authors build the foundation of their polemic. Starting with Step 1 (“We admitted we were powerless over alcohol, that our lives had become unmanageable”), the authors suggest that “compelling as this is as a narrative device, it lacks any clinical merit or scientific backing” (p. 4).
Their examination of Step 2 (“Came to believe that a Power greater than ourselves could restore us to sanity”), exhibits a common misunderstanding of twelve-step recovery. The authors state, without a single citation, that “many scholars have written about the close bond between AA and religion” (p. 4). Here they confuse religion and spirituality. Religion typically specifies the nature of its deity. Spirituality simply posits the existence of a power greater than ours (Kurtz 1991). Those who deify Freud might incite detractors to label psychoanalysis a religion (Fromm 1950).
The issues addressed in the remaining steps, including surrender, character defects, admission of shortcomings, making amends, taking inventory, prayer and meditation, and spiritual awakening (which the Dodes debunk step by step), are similarly dismissed out of hand. Yet all of them are in accord with modern psychoanalytic paradigms such as self psychology, object relations, attachment, and mentalization theory, which help us understand how and why AA works. Kurtz (1991) emphasizes that shame and related narcissistic insatiability are core dynamics in alcoholic disorders and that AA is the treatment of choice for addressing and modifying these. Flores (2004) focuses on attachment issues in addictive disorders and how imperative it is for group and individual psychotherapies to address the interpersonal avoidances and illusory self-sufficiency that are so central to the dynamics that perpetuate addictive disorders. These paradigms help explain how a focus on the steps draws attention to and aids in addressing the vulnerabilities and disorder that predispose to and result from alcohol dependency (Roth 2004).
The authors, so vehement in their rejection of the twelve steps, do not even discuss the “twelve traditions.” Yet these guidelines for group functioning offer the most sophisticated model yet developed for the maintenance and preservation of healthy group functioning (Roth 2003; Mack 1981). Four of the traditions seem particularly relevant in examining the strength of twelve-step groups and the limitations of the authors’ approach.
Taken together, tradition six (“An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose”) and tradition ten (“Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy”) protect the boundaries of AA, preventing it from becoming embroiled in conflicts that might distract its members from their primary task, which is staying sober.
The thrust of tradition eleven (“Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films” and tradition twelve (“Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities”) would seem quite clear. Yet the Dodeses appear to be ignorant of their explicit meaning, maintaining that “AA’s emphasis on proselytizing, a basic tool through which recognized religions and certain fringe religious groups spread their message, is an essential part of its worldwide success” (p. 6).
When the Dodeses betray their misinterpretation of the twelve steps, we react, as may many other mental health workers, as if they have shut the door forcefully on the potentially life-altering possibility for collaboration between the worlds of psychoanalytic psychiatry and twelve-step recovery. Although it may legitimately be argued that the steps, in and of themselves, are not the sole or even the most critically helpful aspects of AA, the Dodeses are in our opinion unfair and far too one-sided in their dismissal and critique of the steps. Other writers have found alternative psychodynamic perspectives than those adopted in The Sober Truth, and discover much in the practice and traditions of AA to support the rationale for twelve-step programs and their efficacy (Khantzian 2014a,b; Flores 2004; Kurtz 1991). The steps and traditions offer a structure and a guide for individuals who have been derailed and rendered terribly lost and confused by the damaging and disorganizing consequences of chronic heavy alcohol use.
For those of us who see psychotherapy as an adjunct to the discipline of AA, rather than as clearly superior and opposed to it, a patient in psychotherapy working on “alcohol issues” and a person participating in AA can reap similar benefits. But far too often, the treatments that are adopted are dictated by rigid, entrenched ideas of what addictions are about and thus what is best suited for particular individuals. The risk is that patients’ needs will be misaligned with what is needed, and will be inappropriate and potentially harmful, even damaging, to those seeking help (Khantzian 2014a,b).
Perhaps no one could have more eloquently acknowledged the potential for cooperation between psychodynamic psychotherapy and twelve-step recovery than Bill Wilson, the founder of AA: “As excuse-makers and rationalizers, we drunks are champions. It is the business of the psychiatrist to get behind our excuses and to find the deeper causes for our conduct. Though uninstructed in psychiatry, we can, after a little time in A.A., see that our motives have not been what we thought they were and that we have been motivated by forces unknown to us. Therefore we ought to look with the deepest respect, interest, and profit upon the findings of psychiatry, remembering that up to now the psychiatrists have been far more tolerant of us than we have been of them. So we thank them for the steadfast friendship and support which they have given us in nearly every quarter of the profession” (Wilson 1955, p. 236). But despite this explicit expression of regard for psychiatric insights, the authors insist in their chronicle of Bill Wilson’s life that “one bedrock tenet of the Oxford Group . . . would influence AA for years to come; an absolute opposition to medical or psychological explanations for human failings and thus a complete prohibition on professional treatment of any kind” (p. 19). Once again, alas, these authors misrepresent important facts about AA.