Epidemiological research tells us that the AA snapshot of alcoholism and addiction and the projection that all alcoholics and addicts end up in jail, in a hospital, or in a graveyard is a disturbing, inaccurate, harmful fantasy. What do we do about this delusion in order to make American policy, science, treatment, and self-help more, well, helpful?
The Stanton Peele Addiction Website, February 22, 2011. This blog post also appeared on Stanton's Addiction in Society blog at PsychologyToday.com.
Addiction in the Real - vs. the Clinical - World
Community-based, real-life (now called epidemiological) research paints a completely differently reality from clinical and laboratory research on alcohol and drugs.
This dichotomy underlies the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) declaration that "Alcoholism isn't what it used to be ," and the denial (which is not a river in Egypt) by the treatment community that what the NIAAA says can possibly be true.
The NIAAA's finding that alcoholism isn't what it used to be (i.e., what we thought it was based on AA and TV and movies et al.) is based on its national survey of Americans' drinking, NESARC. NESARC found that roughly three quarters of people recover from alcoholism with or without treatment (only one in eight alcoholics is exposed to treatment or AA) - and that half of those drink safely.
In broad strokes, this means that a quarter of alcoholics maintain their alcoholism (and a minority of those deteriorate to even worse fates) - at the other extreme, a quarter become fully normal drinkers. In between, a quarter eliminate problems but are cautious drinkers, and a quarter continue to have some drinking issues but carry on with otherwise normal lives.
Huh? That can't be true! We don't believe it because at AA meetings you find all the people who tried to go it alone and failed. We don't see and hear people describe their alcoholic periods (like Steve Martin and Robert Redford) that they emerged from naturally to become non-labeled, normal individuals (with rare exceptions ).
In the real-world, AA is a narrow band of treated or self-identified alcoholics, a tip-top of a pyramid of drinking. Over the entire population, about one in a hundred people fits the AA profile.
And it's just as true about drugs: Patricia Erickson (author of The Steel Drug ) and Bruce Alexander found that roughly 10 percent of cocaine users continue to use the drug for an extended period of time, and 10 percent of those (1 percent of all users) resemble what we think of as the typical cocaine user - the all-out addict.* The overwhelming majority of these people are never treated.
Here are the policy, science, treatment, and self-help implications of this reality:
Policy: The National Institute on Drug Abuse (which didn't get the NIAAA's memo) is built on the idea that drug use = addiction and on finding mechanisms that explain this fiction. It is a political and propaganda arm of the government and the society's zero-tolerance goals. It isn't a scientific body.
Treatment as is: The idea in America is to get all those alcoholics, addicts, substance abusers into treatment that makes them abstain. That will never happen. We can't afford to get everyone into treatment; most people won't go to AA; the people who do go to treatment and AA in the vast majority of cases don't abstain - for better and for worse.
Helping people: If we really wanted to help people where they live, the majority of our efforts would be directed at assisting people to make do in the worst cases (harm reduction therapy+) and to improve their lives for those in a position to do so. My Life Process Program addresses people's addictions not from the standpoint of their disease - but from that of improving their lives.
Self-helping: Given that the vast majority of people - according to the government's own data - won't abstain from alcohol et al., who exactly is out there to support these people, who may be struggling, who can make incremental improvements, who are typical human beings trying to keep their lives upright? (One such group is HAMS .)
Like so many of our ideas and so much of our health care system, we are fighting a misidentified monster at the cost of spending our money wisely, being optimally helpful to people, and being a humane society.
* Patricia G. Erickson and Bruce K. Alexander, "Cocaine and Addictive Liability," Social Pharmacology 3:43-55 (1989).
+ G. Alan Marlatt and Katie Witkiewitz, "Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment," Addictive Behaviors 27:867-886 (2002).