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Is Addiction a "Biopsychosocial" Phenomenon?

Nobody likes people who say "I'm right and you're not." We've all learned to be diplomatic, so nobody's feelings get hurt. Even when we're completely certain we're right, we realize it's good manners to say, "I'm sure there are ways you're right, too," or, "No doubt we both have something useful to contribute to this."

But science is different. The scientific enterprise is about getting closer to the truth, by discovering or creating new understandings, and discarding older ones that we know are misguided. In science, we cannot patiently accommodate mistaken ideas because it's good manners. Some people may still believe that the Earth is flat. Yet it would be very bad science to say, "Hey, no problem. We're can both be right! Let's make a theory that the earth is round and also sometimes flat. Everyone will be happy."

Somehow in the field of addiction, "making nice" has managed to grab a powerful foothold. Ask nearly any psychiatrist about the nature of addiction, and she is likely to support the notion that it is a "biopsychosocial" phenomenon. This word, invented in the late 1970's, was intended to act as a sort of tepid catch-all which included every possible factor in the development of addiction: biological, psychological and social. Everyone's model got a seat at the table. Today the "biopsychosocial" explanation has become standard for virtually every psychiatric problem. And why shouldn't it be popular? "Biopsychosocial" may be the most diplomatic medical term ever invented.

Biology, sociology, and psychology represent three separate pathways to understandingbehavior, which may or may not overlap. If a woman is exposed to rabies, she may begin acting aggressively and erratically, a pattern of behavior that is the result of purely biological factors: she is infected. If a man lacks food and shelter, he will be more inclined to break the law to get what he needs to survive, a pattern of behavior that is psychosocial. And if a person responds to feeling overwhelmingly helpless by drinking or gambling or overeating, this pattern of behavior is psychological.

The lines get blurred sometimes in the study of addiction because these contextual factors may appear together. If an impoverished man becomes an alcoholic, certainly his social state is a factor. But his solution to this particular helplessness is a psychological symptom. Poverty contributes to addiction, but it is not the deepest understanding of it.

Speaking personally rather than scientifically, I wish I could make friends with everyone and add in biological and social factors to the basic nature of addiction. I happen to love biology: I was a biology major in college and did my honors thesis in embryology. In medical school, my favorite of the basic sciences was Histology: deciphering microscopic slides of different tissues.

But science isn't about what you love, or about being nice. Sadly, the "biopsychosocial" idea is doing more good for theorists than for addicts.

Posted on Tuesday, September 30, 2014 at 02:14AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References4 References

How to Avoid Bad Rehab Treatment

Save yourself the expense and heartache.

The rehabilitation industry in our country is, unfortunately, filled with false claims and bogus treatments. When I investigated the success rates of rehabilitation programs for my book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, I found that virtually none of them even study their patients' outcomes, despite claiming fabulous results. And, sadly, rehab treatment usually fails. Research has shown that the majority of alcoholics resume drinking within the first year after rehab, and a substantial percent of these people are drinking regularly every week. Too many people who have been through these expensive and ineffective programs end up with a sense of despair, and even a sense of personal failure. To avoid this, it's first necessary to know the inadequate ways rehab centers treat addiction.

Rehabilitation facilities are allowed to staff themselves any way they like. As a result, most of them are staffed by counselors with negligible training which would not qualify them to be therapists in a more professional setting. Hazelden Treatment Center, for instance, advertises that people can become addiction counselors in just a year, while training to be a social worker, psychologist or psychiatrist requires from three to eight years followed by more years of practical experience before being licensed. And even though most rehabs are saving the cost of hiring well-qualified therapists, many of them charge from $30,000 to $90,000/month.

How do these rehabs justify such exorbitant charges, if it's not by providing highly trained treatment staff? The answer is that they offer, and heavily advertise, expensive "extras" which lead people to think they are getting something special. But these non-therapy extras have nothing to do with treating addiction. Here are some examples: equine therapy (spending time with a horse), "ocean therapy" (taking a ride on a yacht), fitness training, aquatic aerobics, work assignments, leisure skills group, and even more strange approaches (Sierra Tucson offers “qigong therapy” which it describes as an ancient form of Tai Chi, and claims that its benefits include “enhanced immune system,” “increased energy and vitality,” “improved intuition and creativity,” etc.; there is no scientific basis for these claims). In our book , we published the complete daily schedules from the Betty Ford Center and Hazelden which list many of these irrelevant and unproven "treatments."

The most famous and expensive rehabs also compete with each other to offer beautiful settings with spacious rooms and gourmet cuisine, all of which add to your cost, and none of which is relevant to treating addiction. If living for a month with a view of the mountains or the beach treated addiction, there would be no addiction in lovely areas of the country.

All of these programs also de-emphasize individual sessions. Instead, they offer multiple groups. Group therapy is a legitimate treatment, of course -- but not the way they do it. True group therapy, led by a well-trained professional therapist, provides an opportunity for individuals to explore their interactions with others in the group, in order to learn more about themselves and their relationships. What is offered in rehabs as "group" treatment is mostly lectures and discussions about assigned topics.

However, if you are forewarned, it is possible to find alternatives that are both better and less expensive. Here's a short guide:

1. Look for programs that do not have a fixed length of stay. There is absolutely no medical or psychological justification for staying in a facility for exactly 30 days, or any other fixed number. Length of treatment for addiction should be individualized, as it is for every single other medical or psychological hospitalization. You can find programs that average shorter, 2-week stays, and are able to charge less both because they are not as long and because they don't have horses, aquatics, or ocean views.

2. A competent rehab should emphasize individual treatment with truly well-trained therapists. Don't be fooled by places that say they offer individualized care when what they mean is that you can choose among several existing programs, none of which offer individual treatment. The ability to choose one lecture series over another, or horses over swimming, is not individualized treatment.

3. Any rehab worth your time and money must offer a variety of modalities without insisting you fit into their favorite one. A program may offer 12-step meetings, for example, but to be competent it must offer non-12-step approaches for those who cannot benefit from a 12-step approach. A rehab must never be a boot camp to whip you into accepting their belief system. Ask if they are based on a single treatment model for everyone, and if so, stay away.

4. Look for fewer, not more, amenities. Every facility needs decent housing and food, but any place that actually thinks horses and scenery treat addiction is telling you they don't know much about addiction.

Sometimes it makes sense to be hospitalized, because you have tried outpatient treatment and are not doing well. There's nothing wrong with taking a break from a cycle of addictive behavior, followed by depression, leading to more addictive behavior. But if you decide you need that break, choose well, on the basis of the most qualified care.

Posted on Wednesday, September 10, 2014 at 02:11AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References11 References

What Does It Mean to Be "In Recovery"?

Many words in the addiction field have been tossed around for years without being clearly defined or even being meaningful. "Recovered," "recovery" and "being in recovery" are examples. In most of life, "being in recovery" means a person is making progress even though s/he isn't "cured." Sometimes it is used as a synonym for "being in remission" — indicating relapse is a clear possibility (as with being "in recovery" from cancer), while other times it means "on the path to a definite cure" — as in being in recovery after surgery. Neither of these usages is problematic, so long as we all understand what is meant. But in the addiction field, the term has been used in a third way in 12-step programs. There, it is traditional for people to refer to themselves as "in recovery," no matter how long they have been abstinent from their addictive behavior and no matter how well they are doing in life. Partly, this is the same as saying they are "in remission," based on the idea they can always suffer a relapse. But too often, being "in recovery" has come to mean something different: that they are on what they declare is the right path. When used this way, folks are condemned as not "in recovery" if they drop out of 12-step programs or are thought to not be "working the program" adequately. When "recovery" is used this way, it is more a political statement than a factual or medical one.

People suffering with addictions should ignore the agendas of anyone attempting to define whether they are "recovering" or "recovered." They would be better off thinking of their addiction as a repetitive behavior that arises with great force at key moments when they feel overwhelmingly helpless. These moments can be predicted and avoided once they know just what their emotional vulnerabilities are. However, there will always be some risk of becoming overwhelmed, and responding with the old behavior. To this extent, it is true that anyone with addictive behavior is never "cured." But we are all at risk of repeating old behaviors (in my field it's called "regressing"), whether these old behaviors are addictions or anything else that used to be part of our solution to life. That's not a specific feature of addictions, it's just the way humans are. It makes no more sense to label oneself as "recovering" forever from an addiction, than it does for a person who used to be depressed to forever be "recovering" from depression, or a person who has been cancer-free for 15 years to still define herself as a cancer patient. It certainly makes no sense to define "recovering" in terms of whether you are in one treatment approach or another. Addiction is a terrible symptom, but it is not who you are, and once you understand how it works emotionally in you so it doesn't sneak up on you, there is no reason to dwell on what words you use.

[A version of this post appears in my answer to a question on the "Ask an Expert" section of the website, The Fix.]

Posted on Thursday, July 31, 2014 at 02:10AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References4 References

Hidden Moralizing About Addiction

Don't put up with being insulted.

People moralize about addiction all the time. They say that folks suffering with addictions are weak, selfish, pleasure-seeking, stupid and on and on. This kind of nonsense is easy to spot. But some moralizing is more subtle. Here are two examples of hidden moralizing that I've gathered from comments made in response to our book "The Sober Truth," which examines the flawed science behind 12-step treatment.

1. "If you aren't doing well in 12-step programs, it's because you haven't worked at it hard enough. You haven't followed the suggestions. You haven't done the steps." People who say these things probably mean well. They have a belief that if you just followed the program, you'd be well. After all, it worked for them. This is the reasoning in the AA slogan: "It works if you work it." However, the slogan is completely untrue, as we showed in our book (12-step programs have a 5-10% success rate, which cannot be attributed to the idea that 90% don't work hard). Saying that people who don't benefit because they're not working hard enough is unconscionable.

Anyone trained in psychotherapy knows that when people don't seem to be "working" at treatment, whether it is psychotherapy or any other therapeutic effort, there are important reasons for that -- reasons that themselves should be explored and understood. These can range from just feeling uncomfortable revealing oneself to strangers, or shame about what brings you to the treatment, to more serious issues. Anxiety about being open with anyone -- stranger or not -- terror about being attacked or abused, fear of exposing hidden parts of oneself, and many other concerns may underlie an apparent lack of motivation. Professionals are trained to be attuned to these deeper factors. Untrained people naturally jump to the conclusion that if you aren't "trying," you're lazy or uncaring.

2. A corollary myth is: "If you haven't walked the walk then you can't criticize." When this is said of people who are critical of 12-step programs, it is a version of the notion that if you don't have the problem yourself, then you can neither understand it nor treat it (a foolish and dangerous idea in itself; imagine seeking treatment for depression only from people who are depressed). But the hidden moralizing arises when this idea is directed at people who have spent a lot of time trying to use the steps without benefit, and as a result are critical of them. These people are sometimes told they don't deserve to criticize because they didn't really "walk the walk." Why? Well, if they had really walked the walk, they would have been helped!

If you suffer with an addiction and haven't been helped by any given approach, try something else. The very poor success rate of 12-step programs tells us that we must be actively seeking other approaches, including harm reduction programs such as HAMS, LifeRing and Smart Recovery, or—for people who are inclined to be introspective about themselves—the approach I described in my first two books, "The Heart of Addiction" and "Breaking Addiction." You might also want to see a professional who can help you work out what makes you fearful or anxious about engaging in treatment. But don't let anybody tell you that the problem is that you just need to work harder. And don't let anyone tell you that you don't have the right to criticize a flawed approach.

Posted on Friday, June 13, 2014 at 02:08AM by Registered CommenterLance Dodes, M.D. | CommentsPost a Comment | References3 References

The Sober Truth About AA and the Rehab Industry

12-step programs and rehabs fail almost all the time.

I am pleased to announce the release today of my new book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.

In it, I describe the stunning facts about the current national treatment approach for addiction. AA has a success rate between 5% and 10%. An exhaustive scientific review by the prestigious Cochrane Collection, of all AA studies over 40 years, found even worse results, concluding that, "No experimental studies unequivocally demonstrated the effectiveness of AA" in treating alcoholism.

Practically no studies that support AA meet ordinary scientific standards, and all suffer from serious scientific errors. Most cover only a short time for this lifelong condition, or they are spoiled by a failure to account for "selection bias,” or they base their data on self-reports without independent verification, or they commit the grave error of discarding data that does not fit the authors' conclusions. (Invariably people who are happy and sober are glad to let the researchers know how they're doing, whereas people who have resumed heavy drinking are far less likely to respond to researchers' questionnaires or phone calls. Yet in reaching the statistical conclusion that AA (and rehabs) are successful, these people are regularly ignored.)

A logical error arises from these acrobatics with the data: studies tend to show that the people who remain in AA longest are the most likely to succeed. Pro-AA researchers conclude from this that everyone should stay with AA. Of course this is basic, flawed circular reasoning. The people who stay are precisely the 5% to 10% who are doing well. Their success says absolutely nothing about the 90% who cannot make use of the program and have therefore dropped out.

This book also undertakes a clear-eyed review of the rehab industry. These pastoral retreats typically charge exorbitant amounts for the same 12-step program you can get for free in a church basement, adding irrelevant extras such as horse therapy, reiki massage and ocean adventuring to justify the cost. The data is scarce on these programs by design: it turns out that practically none of them have studied their own outcomes or, if they have, refuse to publish their findings. This has not stopped many of them from claiming fantastic success rates. The rehab industry is unregulated and can claim whatever it wants.

There’s no question that 12-step programs have saved people’s lives. But sending everyone with an addiction to AA or its cousins is simply bad treatment that does harm to the 90% who cannot make use of such programs, and are led to believe they are the ones who are failures, because the program is never wrong. It is time to change the national discussion about what is appropriate treatment for addiction, and I hope this book will provide a starting place.

Posted on Thursday, March 27, 2014 at 12:48AM by Registered CommenterLance Dodes, M.D. | Comments13 Comments | References102 References