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The Sober Truth: Debunking the Bad Science Behind 12-step Programs and the Rehab Industry Hardcover – 25 Apr 2014

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Product details

  • Hardcover: 192 pages
  • Publisher: Beacon Press (25 April 2014)
  • Language: English
  • ISBN-10: 0807033154
  • ISBN-13: 978-0807033159
  • Product Dimensions: 15.9 x 2.1 x 23.6 cm
  • Average Customer Review: 5.0 out of 5 stars  See all reviews (1 customer review)
  • Amazon Bestsellers Rank: 223,134 in Books (See Top 100 in Books)

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9 of 10 people found the following review helpful By fionna on 28 Mar. 2014
Format: Kindle Edition Verified Purchase
This excellent and thought provoking book traces the history of AA and the 12 steps programme from inception to the present day, analyses research studies applying the standards approved (and recognised internationally) in the Cochrane Collaboration for healthcare sciences. As I finished it I let out a breath of relief : "This book needed to be written".

The author(s) acknowledges that for some (a relatively small percentage) AA appears to provide support towards becoming sober. However, on analysing that group, and comparing it to the 'do nothing' option he concludes that this is not a statistically significant outcome sufficient to demonstrate the effectiveness of that particular methodology.

It concludes that AA works for up to 10% of those attending but does not...or does the remaining c90%. In fact it seems that close to 90% of people attending AA do not make it past two months. (You will see AA's Big Book take on this below.). He further points out that in no other well regarded area of healthcare treatments would such an outcome be considered acceptable.

Nor would a good scientist blame the patient (as the AA's manual "The Big Book" does). Particularly, he concludes, as the AA programme in fact does little to improve on the 'success' data from the 'doing nothing' option where 'spontaneous remission' levels are similar to AA 12 steps outcomes once errors in data collection and analysis in studies are corrected. In other words a sub set of people who have alcohol dependency are so committed to recovery that they do well whether or not they are in a 12 steps programme or not.

However fellowship and effective social networking are helpful to people dealing with addictions.
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Most Helpful Customer Reviews on (beta) 117 reviews
63 of 68 people found the following review helpful
By tedlyxx - Published on
Format: Hardcover Verified Purchase
The book just goes over years of research showing that AA/NA is not the cure all its proponents make it out to be. The chief problem in the treatment field is the lack of education and proper training of virtually all addiction counselors including social workers. The 12 step model is all they know so they use it as a one size fits all model of treatment and blame the patient if treatment failsor, more likely, toss them out on administrative discharge if they don't but into the treatment model. I recently retired from the addictions treatment field working at facilites as diverse as hospital inpatient detox, drug court, methadone clinic, 28 day inpatient treatment center and the longest at a state run mental health and addiction treatment center. The one common factor in all these places was that just about all the licensed counselors were completely ignorant of the neuroscience of addiction including the long term changes to the brain from addiction which made patients susceptible to relapse and what to do about it. I still see strong confrontational methods being used. One facility I worked at most recently required all outpatients to attend 2 12 step meetings per week as part of the program and to present written proof of doing so. If they lost the proof or didn't attend, the were then forced to attend 3 meetings per week. I tried for over 10 years to get the staff to realize that by foring patients to increase meetings when they didn't comply made the attendance at meetings seem like punishment, all to no avail. The problem with all facilites I worked at except the methadone clinic, the patients were forced into the treatment model with no concern to their individuality.
The amount of information on the genetics, neuroscience, and psychotherapy of addiction is groowing every year. Work by Eric Nestler and George Koob has been invaluable as has that of William Miller and Alan Marlatt in the treatment end.
Dr. Dodes obviously comes from a psychodymanic background when it come to reasons for addictive behavior which is not as effective a model as some of the more recent therapies such as Motivational Interviewing and Minfulness and Acceptance therapies.
This book is just another AA bashing without any really constructive ideas in it. Perhaps he should google some of the research of Koob and Nestler, or even the research of Jan Kar Zubieta on the neuroscience of the placebo.
Since nothing has been done to change the outdated, ineffective model prevalent in the treatment field, Insurance providers should start mandating that evidence-based therapies must be used for reimbursement. Or even that the legal profession get involed and start filing malpractice suits against facilites that do not use evidence-based treatments.
73 of 82 people found the following review helpful
Good For Goose / Good For Gander 9 Mar. 2014
By The Spinozanator - Published on
Format: Hardcover Vine Customer Review of Free Product ( What's this? )
CH 1: The Problem - Despite having a low success rate, AA's methods and beliefs have been codified into our medical diagnosis and treatment systems and our legal system (Not at AA's instigation, by the way, nor are these intrusions always welcome, but AA is considerate enough not to turn them away). Dodes goes over each of AA's 12 steps and explains why none of them have any relevance in treating addictions. "Yea, but is there anything better?" is a frequent question. Dodes answers, "Yes, there is."

CH 2: The Rise of AA - AA may not be the best way to treat alcoholism, but its founders had a marketing genius within their midst - Bill Wilson. Because of poor results in treating alcoholics, mid 20th century mental health professionals were happy to find a place to send theirs. Eventually, addicts of all sorts found homes in for-profit and not-for-profit 12-step programs.

CH 3: Does AA work? - This chapter is not for the statistically lighthearted. Dodes ends with, "Most studies ... are observational in nature, with few controlled studies that might help us determine the results ... an objective calculation puts AA's success rate at 5-8%. Those controlled, randomized studies that HAVE been done reveal an even more discouraging picture: no proof that AA is effective at all."

CH 4: The Business of Rehab - As one addiction researcher put it, "Anybody can make any claim they want and get away with it. It's essentially an unregulated industry."

CH 5: So What DOES Work To Treat Addiction? - Dodes answers - (my paraphrasing) Addictions are just the names we've given to compulsions that involve drugs. The stresses of life can trigger feelings of helplessness in some people who displace these feelings by using drugs or alcohol. Psychotherapy is helpful in exposing the triggers that cause those helpless feelings. With proper insight and guidance, that person will recognize the triggers and face their feelings of helplessness in a direct and rational manner, instead of by drinking or resorting to other addictive behavior.

CH 6: What the Addicts Say - The author asked readers of his blog to submit first-hand accounts, both positive and negative, of their experiences with 12-step programs. Non-edited, these are simply the reports of the 1st ten people who responded and gave permission to use their stories in this book.

CH 7: Why Does AA Work When It Does? - The curative power of group dynamics.

CH 8: The Myths of Addiction - Eleven slogan-like sayings popular in AA, starting with "You have to hit bottom before you can get well," and why they're not valid or helpful. If I had to pick a favorite chapter, this would be it. It is most entertaining and enlightening.

CH 9: The Failure of Addiction Research And Designing the Perfect Study - Dodes describes the difficulties in getting valid studies published in the US. He says if he doesn't give proper credence to the 12 steps, his papers are rejected. He published his latest article in England.

Then he attempts to justify his method - sort of. What he didn't do was to give any hard data for comparison. After all, if you're going to apply statistics to AA methodology, it's only fair to use them on your therapy. Instead, he says, "Serious psychological journals usually manage this problem by reporting case studies rather than numbers ... Case studies have tremendous value. They are, quite simply, the only way to describe treatment."

This is a great book, as were his other two. I agree with almost everything in it. Its downside is that Dodes, by his own admission, makes no effort to quantify his results, while overtly using statistics (among other methods) to dismantle AA. Despite his inference that "It can't be done," I'll be patiently waiting.

There are a few other organizations that provide group-meeting alternatives to AA and not all rehab units espouse the 12 steps - but all of them put together don't have anywhere near the influence of AA. I wish these groups and Dodes good luck in providing more reasonable and scientific alternatives to the AA-dominated alcoholism and rehab industry. At the same time, I wish to give AA its due for the benefit of those who do find its approach helpful.
128 of 151 people found the following review helpful
Comprehensive and groundbreaking 10 Feb. 2014
By Nicole S. Urdang - Published on
Format: Hardcover Vine Customer Review of Free Product ( What's this? )
As someone who has been working with people with addictions for almost 40 years, I know the guts it takes to write a book challenging the effectiveness of 12-Step Programs.

While I had a few minor disagreements with Dr. Dodes on his understanding of REBT (Dr. Albert Ellis was my mentor for decades), and his idea that all addictions are compulsions (I believe they are all obsessions and compulsions, as heroin and cocaine addicts have told me for years that their obsessing about procuring the drug is actually more exciting than taking it), this is an invaluable treatise on how effective/ineffective 12-Step programs really are.

On the other hand, I have seen hundreds of people use AA, Al-Anon, etc. to great benefit. Nothing is a panacea for everyone, and Dr. Dodes outlines AA's rigidity, religiosity, and lack of statistics in very readable prose.

As a holistic psychotherapist, I appreciate Dr. Dodes' view that there are deeper issues triggering addictive behavior. He says they can all be classed under the heading of helplessness. I agree, though I might add lack of assertiveness, a sense of unworthiness, guilt, and perfectionism.

Like Dr. Dodes, I have always had an issue with AA's stance on complete abstinence equalling the only real progress, as it seems to me 360 days of not drinking is a vast improvement on 365 days of drinking. By not crediting an alcoholic for all that self-control, AA actually can undermine someone's motivation to stay sober.

There are so many provocative and well-thought out ideas in this book, I think it ought to be required reading for anyone working in the field of addiction.
17 of 17 people found the following review helpful
By Timothy James Dean - Published on
Format: Hardcover Vine Customer Review of Free Product ( What's this? )
In 12-step meetings, anyone who questions Bill Wilson's (founder of Alcoholics Anonymous in the 1930s) 12 steps to recovery from alcoholism (and now, a host of other "isms" from narcotics to sex to overeating), will be accused of "stinkin' thinkin'." After all, the AA line goes, "it was your way of thinking that got you here, so quit thinking and follow the program." "Fake it 'til you make it," as one of AA's numerous slogans goes. Since the 1930s, AA has grown to be the basis of most recovery programs around the world. Not that there haven't been those who question the 12 steps, from addicts to therapists. There have been those who question AA's requirement of members to permanently identify themselves as an alcoholic (or drug) addict, its philosophy of personal powerlessness, the required belief that a "higher power" is all that can save someone on the slippery slope to destruction, and the possibility to have a "spiritual awakening" as a result of doing the steps.

The most recent effort along those lines is this book by Lance Dodes, MD (and his writing partner). He states his goal in the title: "Debunking the bad science behind 12-step programs and the rehab industry."

This is a slim volume of 160 pages, but there's a lot packed in. Suffice it to say that if you are interested in addiction (to anything) and are willing to take a critical look at what has become the most common, often court-mandated, program for recovery (the 12 Steps), you'll find much food for thought.

Before we get to Dr. Dodes' broadside against the program taught by Alcoholics Anonymous (and all its spin-offs), here's a summary of his position. Addiction is not a spiritual problem. Nor is it a genetic issue ("...nobody in human history has ever walked into a bar because a gene told them to"). Controversially, he claims as well that addiction is not a disease, contrary to prevailing thought in psychiatric medicine and law enforcement.

Instead, Dodes argues, addiction can only be understood from a psychological perspective. Addiction is compulsive behavior. (He makes a distinction between an addict's compulsion and "obsessive-compulsive disorder" or OCD. He claims OCD can be treated with drugs like Prosac, while most addictive behaviour cannot).

Here is the heart of his argument: "...compulsions are driven behavior that people cannot stop themselves from doing, even when they want to...what if addiction is just the name we give to compulsions that involve drugs?... Unlike the OCD symptoms, these compulsions are triggered by emotional factors and can be treated in psychotherapy."

So what, in this model, causes an addict to reach for that next drink or drug, or binge on food, gambling or sex? This is the most interesting insight in his book: "The psychological function of addiction is to reverse the sense of overwhelming helplessness.... The drive to reverse utter helplessness is...the natural human rage to fight against being trapped.... And this rage at helplessness boils up equally when people feel emotionally trapped.... It is what gives addiction its most defining characteristic: an enormous intensity that overrides every other concern and good judgment, and that often seems impossible to stop by either the person herself or those around her...the powerful drive behind addiction is rage at that helplessness." He goes on to argue that addicts' response to helplessness and rage is "displacement": instead of confronting the real cause of their rage, they reach for a drink or a pill. "This is the final piece of the puzzle: Every addictive act is a substitute for a more direct behavior."

This is Dr. Dodes' diagnosis, so what is his remedy? "If addicts can learn to address their rage at helplessness directly, then it manifests simply as an assertive act. When people act directly, there can be no addiction." Of course, there is a lot more to be said about this, and it's in the book.

Why is Dr. Dodes so opposed to AA? He slams it on almost every front, not the least of which is its low rate of success. It's not publicly admitted by the organization, but it is well known that a mere 5 to 10% of those who enter its doors, remain sober. Dr. Dodes spends a good deal of his effort laying out what he thinks is wrong with the AA approach, from its beginnings as a Christian temperance movement (an offshoot of Bill W's encounter with "The Oxford Group" from which most of the steps emerged), to its ongoing heavily religious or spiritual component (reliance on a Higher Power to save the addict from him- or her-self), to its lack of trained therapists, abuses by some members against others (especially newcomers), to the scarcity of dependable studies of the effectiveness of the AA program.

Dodes is most scathing of the expensive, for profit, often celebrity-driven, rehabs centers that have sprung up across America and other parts of the world. He claims they are most often 12-step based, run and staffed by medically or therapeutically untrained recovering addicts, and that they do not record or study the effectiveness of their treatment on their clients or members in any meaningful way. He wonders about all the costly frills, from "equine-assisted therapy," "adventure therapy," to massage, spirituality sessions, meditation, leisure skills, and so on. Add onto this the cost ($30,000 to $90,000 per client per month), and the fact that most of their alumni promptly return to abusing alcohol or drugs, and you have the general basis of his concern.

So what does Lance Dodes recommend as a viable alternative? He does have his own agenda, which is not hard to read, albeit sometimes between the lines. Dr. Dodes is a medical doctor and psychologist with more than 35 years of counseling people with addictions. He is also the author of "The Heart of Addiction" and "Breaking Addictions." He was a senior analyst with the Boston Psychoanalytic Society, and a prof of psychiatry at Harvard.

So, naturally, he recommends psychotherapy as the treatment for addiction. His book ends with an appeal for better studies of AA and all the other treatments for addictions, and he outlines what is, in his view, the best way to go about this. However, to get a glimpse of what he sees as a more appropriate treatment than those offered by AA and its luxurious rehab spinoffs, you must leaf back to page 79 of his book, where it is tacked onto a chapter on "the American Sanitarium." Here, he states, "...a rational program would be individualized...all patients would be seen by an experienced, well-trained psychotherapist multiple times a week, if not daily. Therapists would have to be...up to standards of excellence...." He goes on to say, "An ideal program would also have no need for lectures about drugs or for instructions about how to use 12-step programs...."

As he concludes his book, he tells us: "The addiction field has been dominated by two colossal institutions, neither of which is trained or interested in looking beneath the surface.... One of these forces is AA. The other is the titanic shift in psychiatry away from...human psychology toward...the very popular notion that addiction is a disease." However, he quotes an expert on potential faults in the various studies: "Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings...."

And herein lies the greatest potential fault in Dr. Dodes' own stance: his built-in bias towards the doctor-patient, therapist-client, relationship. He is an advocate of "talk therapy" as well.

Dodes' hypothesis is that addicts need a better option than AA, and this option is highly trained psychiatrists from the medical community. Sounds good, even though some will argue that doctors who are not addicts themselves, have little tolerance for troublesome addicted patients. Knowing the theory does not give empathy for the behavior or the suffering. However, the thing that will scuttle his particular ship even before it sails, is that it is not practical. First, imagine the hundreds of millions of addicts to alcohol, drug, gambling, sex and food (just for starters). Now picture them all in a line to see the psychiatrists and psychologists who are going to be waiting for them. One estimate is that there are 35- to 40-million people with an alcohol problem in the United States. That is the number of every man, woman and child in Canada! Can you imagine the huge army of therapists that would be required to service these people daily, or at least, several times a week? Now multiply this number perhaps by ten to get an idea of how many addicts there are in total, and we see just how overwhelming the scope of the challenge really is.

Dodes (and many others) no doubt voice legitimate criticism and concerns about AA (and its offshoots), and the way they have become embedded in societies worldwide. Yet, as he himself says, 12-step programs do help some addicts recover. Whatever else they may be (and he does hammer home the point that AA is a religious organization), meetings are a place where those seeking relief from their addiction can find like-minded people. To a sufferer whose friends are fellow drinkers or druggies (known in AA as "lower companions"), a meeting where most attending are clean and sober, can be a life-raft they can cling to and haul themselves into.

Herein lies the reason AA continues to fill cheap church rooms all over the world: the program, warts and all, is free. Each group is autonomous, paying its own simple way by donation from its members. Sure, some groups are upbeat and helpful, and others may be run by abusive old drunks. There are a lot of self-admittedly sick people in AA, NA, and all the other groups, some of whom do prey on new members, sexually and financially. Of course, many members cannot stay off drink or drugs, and there is a high dropout rate.

But Dr. Dodes' ideal of medically trained therapists for all addicts sounds wonderful, until you do the logistics. Where will these addiction experts come from, and who will pay them? Recovering addicts? A few well-heeled people, including movie stars, may be able to cough up the money. These are the same ones who now drop their fortunes at the latest-greatest rehab centers. However, in the real world, psychotherapists bill at lawyer-like rates. Most addicts will not be able to pay. So either an overburdened government must do it, or it won't happen.

Still, Dr. Dodes' book does make for thought-provoking reading.

13 of 14 people found the following review helpful
A flawed analysis 21 Nov. 2014
By R. Smith - Published on
Format: Kindle Edition Verified Purchase
I have to admit that I got a kind of sick thrill from the lambasting of 12 step programs. The author makes some very good points about the disappointing statistics of recovery, and the lack of scientific rigor around 12 step recovery. I also kind of enjoyed the skewering of the religiosity of 12 step recovery, which though it is not as bad as the author thinks, is pretty annoying for at least some atheists and agnostics.

The point the author makes about the "disease model" of alcoholism being plainly wrong is really interesting. The author claims that alcoholism is a set of behaviors rather than a disease, and this makes a lot of sense. It does seem to be the case that people with alcoholism also exhibit a constellation of addictive behavior, and that many alcoholics are "cross addicted" to other substances and behaviors. The behavior model explains this very simply.

I was also fascinated by the argument that the principle benefit of 12 step recovery is the fellowship, which reduces the sense of isolation, and therefore the sense of powerlessness that (according to the author) drives addictive behavior.

Having said that, there are some problems with this book.

Right off the bat, the author is claiming that the popularity of AA is due to proselytizing by its members, and cites step 12, "carry this message to other alcoholics," when in fact, that step is more about offering help to people who need it. The author fails to cite tradition 11(?), which is that AA is based on "attraction rather than promotion." In fact, proselytizing is frowned on by members and is discouraged by the literature. So, the author got that wrong right away.

Further, the author claims that 12 step recovery does little better than the "spontaneous recovery" rate. However, there is no sense of the quality of recovery of people who "spontaneously recover". If some of those people are raw nerve endings who might go back to drinking at the drop of a hat, then it is not the same as someone who has bought into 12 step recovery and achieved a measure of peace and serenity. There are no case studies or data in the book to determine which is the case.

The author also claims that telling people they are "powerless over alcohol" increases the sense of powerlessness that fuels addictive behavior, and is therefore counterproductive. However, I think the author fundamentally misunderstands the nature of powerlessness described in the first three steps. It is meant to promote faith in a higher power, from which power flows. Bill Wilson describes this in the 12 Steps and 12 Traditions using the irritating metaphor of being dependent on the electrical grid from which power flows, and I think if the author had read that, it might have explained things.

Regarding higher power, there is no doubt that the literature and the foundation of AA meant the higher power to be Christian God. However, there are many atheists and agnostics in 12 step recovery now (as well as Buddhists, etc.). It is God as you understand him/her/it. Really, faith in a higher power can just mean that you don't walk around anxious all of the time that something horrible will happen if you are not always managing every detail of your life. The purposes is to reduce anxiety and the sense of isolation, and 12 step recovery can do this for some people, even for atheists.

The author spends a lot of time bashing AA, but offers little in the way of practical alternatives, other than proposing how to do a proper study of recovery.

As other reviewers have pointed out, the author claims that one on one talk therapy is far more effective than 12 step recovery, based solely on his personal experience, but that even if this is really true, does not address that there are not nearly enough qualified therapists nor nearly enough money to support this model for all addicts and alcoholics who wish to recover. It just is not practical.

Further, as someone who has tried talk therapy, I can attest that there are enough ineffective, lazy, clueless therapists out there that if you happen to be even somewhat unlucky, you can end up frustrated and out a lot of money after having made almost no progress.

In contrast, for people for whom 12 step recovery works (by the numbers, roughly one in twenty), the results can be pretty great. I have seen former crack addicts who are now business owners, spouses, and parents, and who are truly happy with their lives, and unlike the author, I am sure that 12 step recovery directly contributed to this transformation.

So, yeah, the author has his points. Bill Wilson was a wanker, the numbers aren't good, the religiosity is irritating to some atheists, there is no scientific basis for 12 step recovery. Whatever. When it works, it works, however rarely, however imperfectly. The real question is does it do more harm than good. The author says yes, but at least in this book, he did not convince me.
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