A Critic and an Advocate Debate the Pros and Cons of the 12-Step Model

Shutterstock

Can you both state your view on what addiction is, and where AA and the 12 steps belong in your framework?

JOSEPH NOWINSKI: Addiction is a process that develops over time in an individual. Whether it be alcohol or drugs, those are the most commonly talked about ones, but it could also be things like gambling. What doesn’t happen is that a person wakes up one morning and decides to be an alcoholic or an addict, it’s an insidious process.

Alcoholism and addiction gradually progresses along with what the American Psychiatric Association (APA) considers a spectrum. Rather than moving from one category to another, people move along this spectrum and cross into a border, again not a sharp line, but what might be called a mild-alcohol use problem where the person begins to experience some very mild and occasional consequences, like hangovers and loss of energy. What happens if use continues is that the person moves along this spectrum into a moderate alcohol problem and then ultimately into a severe problem, which is what we typically call drug or alcohol dependent.

If we want to understand addiction we have to understand how addiction works as an attempted psychological solution.

And what happens to the eventual addict is that his or her drinking or drug use will begin to have more and more of a negative impact on the lifestyle of that person. This could be emotional, psychological (i.e. mild-depression, loss of energy, suffering work performance and relationships) and the person often fails to connect the dots until he or she is pretty far along that spectrum. The end point of which, is what you might call addiction, where the person who uses alcohol or drugs or gambling, whatever it is, has been making his or her life unmanageable.

The loss of control in addiction is caused by the addiction itself. This results in the person’s life becoming progressively—and to quote AA’s first step—unmanageable. And Alcoholics Anonymous, on the outset, has been basically a program of attraction, the qualifier to attend AA or NA or, not even just those, it could be Women in Sobriety or SMART Recovery, has to be a desire to stop drinking or using. Typically, people who have gotten to this point experience significant negative consequences. At that point, the best option for them is to try to abstain from substances.

So my view of AA, and where I depart from Dr. Dodes, is that the research clearly shows (everything from AA surveys to longitudinal studies to clinical trials) that the 12-step approach is effective, especially for those who are in that moderate to severe stage of their use.

Dr. Dodes, your view?

Dr. Lance Dodes/ Photo via

LANCE DODES: Well, to begin with, Dr. Nowinski is describing the behavior, not the reason people drink. So, if you look at it from the outside in, superficially, you could say that there is a process because the behavior gradually gets worse. That does not tell us anything about why it gets worse, the cause, or what the treatment should be. To define alcoholism by its results might give you a description of it, but it’s not going to help you anymore than saying that if you have pneumonia, you’re going to end up doing a lot of coughing and having trouble breathing, without understanding its cause or treatment.

Second of all, it is circular to say, as Dr. Nowinski did, that the loss of control is the addiction and that is caused by the addiction. A better way to talk about addiction is to say first, that we know addictive acts are not random. They occur when people are under some sort of stress. Although there are a few people who just drink all the time, the great majority of people suffering from alcoholism do so episodically, i.e., they drink for a weekend or they drink for a week and then they stop and then they do it again. And these reoccurrences, which become the norm, are produced by something or precipitated by something.

We also know that the sort of things that precipitate them are some kind of emotional distress, which is individual to each person. It is commonplace to hear that people start drinking when they experience the loss of a relationship or a death or some failure at work leading them to be discouraged or depressed. Any of the variety of things that cause you to feel bad or overwhelmingly anxious are things that we know that can precipitate an addictive act. Other times, even people who are addicts, don’t do their addictive behavior. So if we want to understand addiction we have to understand how addiction works as an attempted psychological solution.

Another example of this is that, as Dr. Nowinski correctly said, addictions have multiple forms, certainly not restricted to drugs. But there are also forms that we do not even call addictions. For example, a patient I saw who was abusively using the drug Percodan (aspirin and oxycodone tablets) came in one day came and said that "I have stopped using Percodan, which is good, but I’m afraid I’ve gone crazy." I said, "What do you mean?" She said, "I cannot stop cleaning my house; I’m cleaning it with a Q-tip." I think we would all agree that she had simply substituted another compulsive symptom for her compulsive drug use. People regularly switch from behaviors that we call addictive to other compulsive behaviors. This underscores the fact that addiction is neither more nor less than a psychological mechanism that can be understood and treated as such.

Once you accept that, it takes addiction out of the realm of a specific, mysterious, spiritual disorder and is moved over into a psychological symptom, which is actually identical to what we call compulsions. And, in fact, people switch over all the time.

The bottom line is that we should be looking at the causes not just the disastrous results of addiction. When we do that we discover that addiction is an understandable symptom arising from a person's mind.

Dr. Nowinski, care to respond to anything that Dr. Dodes just spoke to?

Dr. Joseph Nowinski/ Photo via

JN: Well, we agree on certain things, like that there are many emotional factors can mark the beginning of it, but here is where we depart: The addiction does take on a life of its own and the hallmark quality of which, is tolerance. The person needs more and more to feel better. And at some point, it is the addiction that creates the unmanageability in a person’s life. Yes, it is true that many people who enter recovery may have to deal with unresolved grief or loneliness or find alternative ways to deal with stress. People who are in recovery have known that for a long time. This is where AA comes in, that is where group support comes in as basically, at this point in time, the best way to overcome the addiction.

According to Dr. Dodes' psychodynamic model, addiction is the result of powerlessness, but from my point of view powerlessness is the result of addiction.

LD: Regarding the question of whether or not addiction has a life of its own, I think what Dr. Nowinski is referring to is that sometimes because your life has gone badly, you do the addictive behavior even more. But that again is a question of the consequences, that doesn’t mean addiction has a life of its own, it is merely a worsening of the same thing. In fact, we know that people stop doing their addictive behavior with all kinds of interventions, and without any interventions. So, the idea that it has a life of its own, that it exists as a thing in itself, is just not true. People have sudden changes in their circumstances, which lead them to stop drinking. Indeed there is a spontaneous remission rate, which has been studied for alcoholism. This rate happens in something like 5-8% of people per year. Those people are just stopping. It turns out addiction didn’t have a life of its own for them, they just stopped for whatever reason. Plenty of people will tell you that anecdotally. Finally, and I know we are going to come to this later, but, Dr. Nowinski says that AA has been shown to be effective. That is just not true. And all the studies show that AA has a known success rate between 5-8%. That’s it.

Dr. Nowinski, in your newest book you cite study-after-study, which shows that 12-step facilitation is an effective treatment and that AA promotes abstinence. So where’s the discrepancy?

JN: I do agree that there are some people who spontaneously remit. And there are some people who are able to conquer an alcohol or substance or behavior problem. But I’m talking about those people who can’t, who from natural experience find themselves unable to stop.

So yes, I think where we part ways is that in my book, I cite a number of prominent researchers in the field of addiction, who publish in the Journal of Substance Abuse Treatment, who say as a group, collectively, and I’ll quote: “longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and less in health care costs. Therefore, there are humane and practical reasons to develop self-help group supportive policies.” That is a group of prominent researchers that I cite in my book. I don’t see where there is an argument that it is harmful to 90% of the people who try it.

LD: Let me ask a question. Dr. Nowinski, have you read my book, The Sober Truth?

JN: Yes, I have. Well, to be honest, not the whole thing. But I have—

LD: OK. Did you read the chapter that includes all those statistics, called “Does AA Work?”

JN: Yes. I‘ve read the Cochrane (2005) and—

LD: Let me take my turn then. I can go through all the studies if you would like, and that study (Cochrane, 2005) reviews all the major studies. I know where Dr. Nowinski is coming from and we have addressed that in our book. So, let me summarize the results very quickly. The bottom line result that the success rate of 5-8% is a fact. What Dr. Nowinski is referring to is something different. What he is saying is that the studies show that if you stay in AA and become deeply invested in it, that if you become involved in the steps, you make the coffee, go to many meetings and stay for a long time, that you are more likely to be doing well compared with people who don’t go to AA. That is a true statement.

The problem is that it is a logical error to conclude that this has relevance to anyone besides that small successful group. When you take people who are self-selecting, as Dr. Nowinski has said a couple times now—it is a program of attraction, those who stay in AA are self-selecting—you are getting a biased sample. You are getting people who want to be in it. But overtime, in every single one of these studies there is an enormous dropout rate.

In the most famous study (Moos & Moos, 2006) conducted over 16 years, 83% of the people dropped out and the conclusions were drawn from the 17% who stayed. But the only people who do stay are the people who are doing well. Everyone else dropped out in a crucial scientific error, they didn't get counted. You are left drawing conclusions on the basis of the people who are doing well—people who are staying precisely because they are the small group that does well. This is an obvious example of circular reasoning. To conclude, as these papers do, that staying in AA for a long time is a good idea for everyone is exactly backwards and dangerous. Only the small percent who can benefit should stay. Everyone else should leave AA when it isn't helping. For the 90% who can't benefit, staying doesn't make them better, it wastes their time.

I don’t mind having AA, I think for the 5-8% who can make use of it, it is fine, it is cost-effective, no problem. But what we do in our society is we tell nearly all people with addictions to go to AA and stay in it. It's clinically recommended. That is deeply harmful because we know that only a small percent of them are going to get well. What happens to the others? They do try, and they stay months, years sometimes, and do badly. We all know the horror stories of people who’ve spent years of their lives in AA without being able to make any use of it. They are told by their families and friends: Don’t be a failure, don’t drop out. AA itself says, "Stay with the program." That is the real problem with AA. It should be a tiny part of the whole treatment system and nobody should be told go. You can’t make people get out of it what they’re not going to.

JN: It is not true that the researchers I cite in my book tell people to go to AA. There are longitudinal, naturalistic studies that I cite, where people just study a group of people from the beginning. No one was told to do anything. And in the 16-year study (Moos & Moos, 2006) there was not that high attrition rate. They simply followed these people for that length of time and those studies show that people who had a higher participation in AA, over those 16 years, had a higher success rate in terms of remission and that those who dropped out were more likely to relapse and remain non-remitted.

Another by the Kaskutas Group (2009) found that those people who chose a low-to-moderate level of involvement, less than 50 meetings in the first year, three years later had higher abstinence rates. Again, I don’t see how it only helps 5-8% of people because of a low attrition rate. Now it’s true that not everybody chooses to go to AA. It’s a personal choice and I agree with that completely. But I think that the studies I’m citing in my book show that those people who choose to get more involved do better; there is a higher abstinence rate.

LD: I may have been unclear, because what I was saying was not that these people in the naturalistic studies were told to go to AA. I agree. In fact, that was the problem with these studies; that they were naturalistic. In other words, people self-selected in to AA. That is a problem for a study because of what I said: If you take only the people who are interested in going you get a selection bias and it simply doesn't reflect the general population.

You’re actually saying what I say: those people who like AA, who want to go to AA, who become invested and who are doing well, stay in it and do well. No one questions that. What I’m saying is that the conclusion you’ve just cited—that people who stay do better—has been disastrously taken to mean should be told to go and stay. That is backward logic. You’re telling people that even though it is not helping you—true for 90% of them—stay in it. That’s the danger. As far as these specific studies, I’m afraid what you’ve said about the Moos & Moos (2006) study is not right. That study is the one I’m talking about with the 83% dropout. They drew their conclusions from that tiny percentage that stayed.

Let me go back to the Cochrane Collaboration that you mentioned. The Cochrane Collaboration is perhaps the most prestigious scientific organization in the world. All they do, their reason for existing, is to vet other scientific studies. What they did in 2005 was looked back over the last 50 years of studies on the effectiveness of AA and TSF (Twelve Step Facilitation treatment). They said let’s look at only the studies that are scientifically valid, which are randomized, controlled studies. When they looked at those studies there was no evidence that AA works at all. Now, I don’t believe that is completely true, we know AA helps some people, but there isn’t much scientific evidence for it. So, to say that it’s the right thing for people with addictions to do is nuts. Again, I’m not saying that AA shouldn’t exist, but I think we should be prescribing it to the small percentage of people who can make use of it. And we should never tell somebody if they’re not benefiting to continue to go. We should tell them to get out.

JN: Since that Cochrane (2005) study, and in my book, I cite a lot of randomized clinical trials and other kid of controlled rigorous research more recent than that in—

LD: So does mine. The Moos (2006) study was after that—

Go ahead Dr. Nowinski,

JN: There are more recent trials published in 2012 and 2013, but the fact is that the dropout rate from the Kaskutas (2009) was not that high. There are more people who decided to give AA a try but the question is, at what level? Some of them decided to be minimally involved and some decided to be highly involved. There was an interesting group that decided to become very highly involved in the first year and all but dropped out after that. That is just a naturalistic following of what people choose to do. They found that the people who had moderate involvement, consistently, over the three years were more likely to stay sober than the low involvement group. But even the low involvement group didn’t do so badly. And the people who started out with a big bang, they ended up doing not much better than the low involvement.

Again, this is a matter of personal choice, no one is saying, "I think that you have to go to AA." The question was, this idea of forcing people to stay in AA because you think it’s good for them. It’s not that. It’s a personal choice.

We’re saying the same thing, but you’re putting a slant on it, that as I’ve stated, is a logical error. That’s all.

LD: I think we’re saying the same thing, that it is a personal choice, and that we shouldn’t say AA is the right treatment or the best treatment for everyone. It’s far from it. For those people who can use it and benefit, I say go. But that’s a tiny percentage of the population. We need to shift our entire culture so we stop thinking that AA is the right thing.

Dr. Nowinski’s book is entitled, If You Work it, it Works, that is a statement that repeats this logical error. It works if you work it means those people who stay for a long time and are doing well, are doing well. That has nothing to do with saying it will do well for anybody else.

JN: No, I don’t think that’s true. What the book says is that based on a large and growing body of research is that people—again, we’re talking about people who say they have a significant drinking or drug problem, many of whom have ended up in rehab or are seeking treatment of some kind—who get involved in treatment or a support group like AA, or it could also be another one, it could be SMART Recovery, it could be Women for Sobriety, those people tend to do better than those people who don’t avail themselves of a support group.

LD: We’re saying the same thing, but you’re putting a slant on it that as I’ve stated is a logical error. That’s all. I mean, we know that people who stay longer do better. That does not mean anything about the effectiveness of AA for the overwhelming majority of people.

Currently, the majority of treatment centers right now are rooted in 12 step. How would we go about getting treatment centers to administer other treatments? Or is there really a “hijacking” going on in the treatment industry? I think where some concern stems from is that people feel there are not other options. So as researchers, experts in the field, how can some collaboration start happening where people don’t feel that their needs are being ignored?

LD: So, I think this is more of a political area than a scientific area. In our book we looked very carefully at rehab and what science there was behind it and we found there is virtually no science behind it. Practically none of the rehabs, especially the major ones, have ever done any research on their outcomes. We did look at what little data there was available and it shows very poor results.

What you’re paying for at a high-end rehab like Hazelden-Betty Ford is a lot of nonsensical unproven treatment. It is AA-based, which you can get for free in any church basement, so that part isn’t worth spending money on. And then they have things like exercise therapy, horse therapy (I’m not making this up), and yacht therapy, ocean therapy. This sort of nonsense goes on all the time at expensive rehabs and it is not worth paying for.

There are a few non-12-step rehabs and it’s hard to know exactly what they are doing. Some of them may be better than others. But nearly all of the rehabs suffer with the problem that they do not have qualified people working there. The counselors, such as they are, usually have very modest counseling experience and some don’t have any training except their own experience being recovering alcoholics, which is not a credential to do anything except feel good about yourself. Some of them do have modest counseling experience

Hazelden has its own educational foundation in which they say they’re going to train counselors. This training is under a year, and probably teaches them what Hazelden uses, which is TSF, and that has been shown to be ineffective.

People who are real therapists spend years becoming real therapists. Dr. Nowinski has a Ph.D., which took him a long time. I have a doctorate as well. It takes a long time and a lot of years to become an expert. These rehabs are staffed by fairly untrained people. So, if you add that to the fact that rehabs generally offer little or no serious therapy, rehab is a bad idea.

Dr. Nowinski, your book is published by Hazelden-Betty Ford. What are your thoughts on rehab and their effectiveness?

I don’t carry a brief for Hazelden. But let me say this, that I agree to the extent that not all rehabs are created equal. I’ve seen and I’ve gone to rehabs that said they were 12-step oriented and they didn’t have any AA. Not all rehabs that say they are 12-step oriented really integrate the 12 steps into their treatment at all. There are also rehabs that are more like vacations that Dr. Dodes points out. I’ve gotten brochures from rehabs in Arizona about trail rides? To what extent that has to do with recovery from any kind of addiction escapes me.

And the other issue, frankly, is the misperception people have that rehab equals recovery. That you’re going to go some place for 28 days and your longstanding alcohol or drug abuse problem is going to miraculously disappear 28 days later. I think that is really misleading people.

Here is where we depart again. I did training at Hazelden and I know for a fact that a large part of what they do there is they try to integrate that initial rehab experience with what’s going to happen afterwards. And that includes AA, but it also includes therapy. We talked about the Moos study earlier, and that is interesting because the Moos study showed that the group of people who chose to go into treatment and therapy, and AA or NA, at the same time had the best long-term outcomes. So, I don’t see rehab as the solution, I see it as a starting point for people, again, those whose lives have gotten out of control from alcohol or drug abuse. I really do think that support group follow-up is important, whether that’s AA, SMART Recovery, or whatever one chooses, the research clearly shows that having a support network that will support your effort makes a difference.

The Fix recently covered the tragedy and controversy of Audrey Kishline, founder of Moderation Management. Is there any lesson to be learned in her story?

LD: The individual life of any one person is irrelevant to the value of that person's ideas. For anyone to use her personal story to condemn her idea is contemptible. Harm reduction is a useful concept and deserves its place in the armamentarium of approaches.

JN: It is always a mistake to equate an individual's ideas with their personal circumstances. In Audrey Kishline’s case, those circumstances were tragic and led her to eventually choose abstinence over moderation as her personal goal. That said, there are many people whose drinking falls outside of what is generally considered “low risk,” resulting in mild disruptions in their functioning or overall sense of well-being. For those individuals, strategies do exist for helping them reverse course. The key, of course, is for each of us to have the courage to honestly assess our drinking and its effects on our lives, and to choose a goal that is most likely to restore us to full function and inner peace.

Keep in mind that research has shown that people who choose abstinence (as opposed to “quitting for a while”) as a goal have better outcomes. And, as you well know, I advocate reaching out to AA or any fellowship that supports abstinence as part of the means to achieving that goal.

LD: If stopping were a matter of a simple rational decision there would be no addicts. As for what approach to take for treatment, I've said for a long time that people should obtain an evaluation from someone who is well-trained enough to be aware of every option. The current practice of thinking of AA first and everything else later has been a public health catastrophe since only 5-8% of all people referred to AA will do well, leaving the vast majority with the wrong treatment. Proper practice would be to triage people to what is likely to work best, just as we do for every other important medical or psychological problem. If we do this correctly, we will end up sending no more than 10% to AA, some other percent to a harm reduction program, some other percent to psychotherapy, and so forth. How to do this triage is a topic in itself, but the bottom line is that people should be told to try something different if what they're doing isn't helping. That's especially true for AA, which discourages people from ever leaving, causing countless harm.

Right now, as it stands, the AMA classifies addiction as a disease. What are your thoughts on the disease model? Do we need to go back to the drawing board? Is addiction located anywhere in the brain, in the body, the way every other disease manifests?

JN: No, I don’t think so. So Dr. Dodes and I are probably in agreement about this. I think that the medical model, the disease model, was convenient in terms of being able to qualify it as a psychiatric disorder way back when.

I mean, there are, for example, twin studies and so forth, that show that there may be some kind of constitutional vulnerability, that if you have a twin who has alcoholism or an identical twin, there is a higher concordance rate. But it’s not 100%. Even if you have an identical twin who is an alcoholic, it doesn’t mean you will become an alcoholic. There are clearly other factors that largely point to the fact that there are psychological issues that lead one down the path of addiction. It is what happens once you go down the path that we disagree about. I really think that AA and support groups make a difference. I don’t think that it is a disease located at some point in the brain.

Care to expand on your thoughts about the classification Dr. Dodes?

LD: Concerning the twin studies, Dr. Nowinski is right, that there is not 100% concordance. In fact those studies show that it is less than 50%. So, if you have alcoholism and have an identical twin, there is less than a 50% chance that your twin will have alcoholism. That gives you some perspective on the genetic issue.

JN: According to Dr. Dodes' psychodynamic model addiction is the result of powerlessness but from my point of view powerlessness is the result of addiction. As I’ve said, addiction does take on a life of its own and it can have psychological triggers. There is no question about that. And that’s true if someone gets involved in AA, they will tell you that in the process of recovery, in working a recovery program for a number of years, they will have dealt with issues like grief, dealt with issues like loss, and they will have dealt with stress and many of those issues that you are talking about. Those issues are recognized.

The group support, I’m saying, clearly, is essential. I don’t think there are a lot of clinical trials that show psychotherapy, in and of itself, is effective compared to any of the other treatments.

LD: People don’t do statistical studies on serious psychotherapy. It’s almost impossible, for a lot of reasons, including the fact that it takes a long time. When people have tried to study psychotherapy, they have mostly looked at very short time periods: three months, six months, one year. Doing that, you’re unlikely to show many results. Most people in therapy discover that it takes quite a bit longer than that to make fundamental changes in their lives.

That’s only one of the issues. The second issue is, in all the studies that have been done which look at what they call professional therapy, they often don't define what that is. And when they have defined it, they never looked at psychodynamic therapy and certainly not a modern approach to it.

Project MATCH, which was the largest said study ever done, in the 1990s, looked at three kinds of therapy: TSF, CBT, and MET. It found that none of them were effective. It was kind of disappointing because the results—Dr. Nowinski is shaking his head—but let me just say that those people who reviewed it found that the effectiveness of those therapies, alleged effectiveness, occurred before 97% of the therapy was actually done. So there was an initial spontaneous response, but it wasn’t due to the therapies they examined.

We as a culture look for quick results. There is no question that addiction is a behavior that you would like to stop as quickly as possible, never mind whether you’re getting at the issues underlying it. But for the vast majority of people who don’t do well in AA or any other treatment, rather than wasting your time doing something that will not help you at all, you should try something that will help you in the long run. Also, no one has ever statistically studied the approach that I’ve been recommending for about 20 years. What I’ve described is a new way of understanding the psychology of addiction, which is I believe more sophisticated than simply looking at the behavior. It is based on the simple concept that if you know the kind of emotional issue that leads to your feeling overwhelmed, you can predict when it will next occur.

I have patients who can tell me right now that next Wednesday they’re going to have their addictive urge. Seems like a miracle, right? The reason they can do this is that they know what’s coming up on Wednesday and they know that is going to emotionally trigger the old compulsive drive. Being forewarned, they can do lots of things, including avoiding the circumstance. But they can also think the issue through in advance, now that they have an understanding of what feels overwhelming for them. Ultimately, they can work out why these circumstances always make them feel so trapped, so that they don’t need to respond to them by having an addictive behavior.

Dr. Nowinski you—

JN: (laughs) Can I respond?

Yes, you were in charge of the TSF group for Project MATCH. What’s your reaction to Dr. Dodes' interpretation of that study?

JN: I didn’t think I’d come here tonight defending Motivational Enhancement Therapy and Cognitive Behavioral Therapy. The truth is, all three treatments were found to be effective and that was what was so surprising. And what they found was that TSF was about 10% more effective than the other two (MET and CBT). But I’m not someone who would say to not try MET or CBT. What I would say, is that on top of those therapies, to get involved in some kind of supportive fellowship.

To be honest with you, CBT has a lot in common with TSF. It has a lot in common with what people hear in AA about avoiding people places and things and is really in line with the AA culture. I beg to differ and think they are both effective.

Now, I’m not going to say that I don’t think people should do psychodynamic or psychotherapy, in addition to a support group. I have no issue with that. I do think that recovery is a long-term process just like how long-term psychotherapy is a process. And to some extent we are definitely concerned with short-term solutions in our culture. A few years ago there was something that came about called Single Session Therapy—basically the epitome of that. Basically, you walk into a therapist’s office and you’re told to snap out of it or something like that.

I’m very interested in people who have long-term recovery and when I come across people who have that, I like to interview them. They view it as a long-term process, that it is not something that occurs over six months. I support that. I also support that people get into long-term psychotherapy, concurrently, because a lot of the issues that drive addiction are grief, loss, loneliness, history of abuse, and are not necessarily overcome in five or six sessions of psychotherapy.

LD: We agree on that. And I don’t want to stay on Project MATCH because it is not worth the time, but let me just give you this one quotation, this is from a 2005 paper by Deborah Dawson (and colleagues) called “Recovery from DSM-IV Alcohol Dependence,” a summary of the Project MATCH data from 43,000 people. She said, “Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However, this effect appeared to be present at week 1, before most of the treatment had been delivered.” So, to attribute even this small percentage of benefit to the effectiveness of treatment wasn’t justified. But I don’t care that much about Project MATCH. It is really in the past and most people consider it kind of a disappointment.

JN: Well, we disagree. I guess leave it at that.

OK. I want to address a lot of the comments I read on The Fix and elsewhere that, a lot of people speak to being in AA and then leaving because of “dogma” or “religiosity” or simply “outgrowing it.” Should AA modernize? Would it attract more people and would more people stick with it if efforts were taken to engage with the present day?

JN: My answer is no. I think that AA has evolved a great deal. If you look at AA, there are certain groups that we may call “orthodox” and if you walk into that group it may be very spiritual, may even be Christian. I have been involved in a lot of research and I know for a fact that if you look at the AA meeting lists in a place like San Francisco, and other large cities, you find groups that list themselves as agnostic, as atheist, as bisexual, gay, lesbian, you know, AA, is not centrally controlled by dogma. It is a spiritual fellowship to the extent that it advocates things like altruism and honesty, if you want to call those spiritual values. But it is not a religion: no clergy, no dogma, no central control.

And I tell people that if they do go to an AA meeting where it happens to be a group of people who are talking about religious beliefs that you feel uncomfortable with, shop around until you find something that you are comfortable with. On the other hand, there are those people who are looking for exactly that type of group.

So I don’t think AA needs to change, it has proven to be immensely adaptable.

LD: I think it has to be true that if AA took out some of the objectionable parts more people would come. You hear that from a lot of people as you say. I think Dr. Nowinski is right, when he says, if you are going to go, choose the right group. But I think there is another message in that: Since AA is not centrally controlled, AA itself really doesn’t quite exist. What AA claims as treatment are the 12 steps. But, in fact, people modify them. Some people emphasize this or that, even the AA slogan, “Take what you want,” tells us that this is not like giving someone penicillin or even giving somebody psychotherapy. This is something that has to do with group support so it is whatever you want to use it as. For that reason, to say that AA is a thing we should recommend is like saying that group support is something we should recommend. Dr. Nowinski has said many times that what is important in AA is “group support.” He is right. That is what AA is. Forget the 12 steps. They are merely a structure. AA is a group support system and it works exactly to the extent that you would expect group support to work to deal with addition. It works for lots of things, but to say that AA is a treatment for addiction is not really so.

I do want to clarify one other thing because you quoted me as recommending psychotherapy. I don’t want to say that. That is not what I’m saying because a lot of people can’t use psychotherapy, either.

So, I’m not saying that everybody has to see a psychotherapist. That wouldn’t be possible. I’ve suggested to rehabs (who don’t really listen) that even though you are based on group treatment, you can use my ideas in a group quite well. It is cost-effective and gets people to think about themselves in a new way. But the bottom line is that we need to have an approach where people are carefully being screened and triaged to the best treatment for them. Five to eight percent will do well in AA and they should go. An unknown percentage will do well in psychotherapy and they should go. Don’t stay with anything that is not working for you. And be patient, because I wish there were magic, but there isn’t any.

Dr. Nowinski, care to chime in about what you think we need to change and in what direction we ought to be going?

JN: I don’t know that I have an idealized treatment to be honest with you. Where we ought to be going is, well, I wrote my book for two reasons. First, so practitioners in the field often are not, even if they are recommending AA, always necessarily in the know as to why they are recommending it. So, the reason I wrote the book was to put in plain language some of this research that has been done, so that the therapists out there who are not researchers can understand why they are making these recommendations. What kind of choices should they be advocating for their clients and why? Secondly, I wrote it for the consumer. I don’t know about you, but I do not like going to the doctor who recommends a treatment for me and can’t tell me why he thinks it will work. It is for consumers, for those who are thinking about support groups, if they are thinking about AA or anything else, to get informed about it through the research. From there, they can then go on and make their own informed decisions. That is the direction I want to see the field going in, being more informed as practitioners and more informed as consumers.

LD: It is a good debate and I think we are both agreeing that something needs to change.

The moderator of this debate, Zachary Siegel, is a regular contributor to The Fix. He last wrote about whether AA is at fault for the murder of one its members and interviewed Ethan Nadelmann. Follow him on twitter.