On October 9, 2010, I had the privilege of sitting down with Dennis McCarty, PhD to discuss drug and alcohol addiction treatment in the US. I have the great fortune of working with Dennis, mostly by turning his printouts into PDFs and booking the conference room for him, and I’ve always been fascinated and heartened by the work he and his team does; I’ve secretly always thought of him as a bit of an unsung superhero – out there fighting the good fight. After reading some posts about drugs, addictions, and treatment here on TNB in recent months, I asked Dennis to share his thoughts on all of it from the angle of policy. Here’s what he had to say.

Recently, I’ve been involved in an academic debate regarding the concept of alcoholism and addiction as diseases. During that debate, I discovered what I consider to be a major contradiction between the diagnosis of alcoholism (upon which I will focus in this post) and its “treatment.” That discovery led me to a second and even more startling revelation.

Without doubt, the advent of alcoholism as a disease accomplished some positives. E.Morton Jellinek was the major force behind the development of the disease model. Without going into Jellinek’s ideas and the conclusions he reached from his research, some of which are unquestionably wrong, it need only be stated for now that without Jellinek, alcoholism might still be considered the result of “character defects.”

Redefining alcoholism as a disease seemingly de-stigmatized alcoholism. However, that de-stigmatization occurred only in the definition of alcoholism, not its treatment. That contradiction is the subject of this essay.

While nearly every therapist, psychologist, psychiatrist, and physician in the United States accepts the disease model of alcoholism and other addictions, they almost-uniformly refer every one of their patients to AA as the one and only road to recovery. Remember that these professionals have, as part of their acceptance of the disease model, obviously concluded that diseases are not caused by “character defects.”

But at the same time, in its primary document (the Twelve Steps), AA members “must” (of course they can ignore it, but no reason to attend AA exists in that case) accept the 6th Step, i.e, being “entirely ready to have God remove all these defects of character” [bolding and italics mine].

This raises two points, the first being the most important.

  • (1) Because almost all therapists, psychologists, psychiatrists, and physicians accept the disease model of alcoholism, they also by default accept that a disease does not result from “character defects.” However, the only “treatment” they offer is referral to AA, which, while paying lip service to the disease model, clearly views alcoholism as the result of “character defects,” otherwise known as a “sinful nature.” Such “treatment” negates the very essence of the treatment community’s own diagnosis. That’s precisely parallel to a physician who knows the use of shark cartilage as a cancer treatment goes against everything he believes about the disease of cancer, but he still points every cancer patient to shark cartilage as the only treatment that “works.”
  • (2) Because AA accepts the disease theory of alcoholism, at least on the surface, its own 6th Step repudiates the definition of alcoholism as a disease and AA as a coherent “philosophy.” AA inculcates the idea of alcoholism as the result of “character defects,” the very idea Jellinek, the founder of the disease model, disputed. Thus, AA is entirely based upon a “sin and redemption” approach. While it may work for some, it is, without question, a faith-based organization, as both the Twelve Steps and the fact that, at least in my experience, every AA meeting ends with the specifically-Christian Lord’s Prayer and the Serenity Prayer (“God grant me the wisdom…”) attest.

Point (1) is far more important than a blatant contradiction. That the sole recovery model to which patients are referred denies the very diagnosis and understanding of alcoholism that the entire treatment community accepts is an almost unbelievable fact. Of even more concern is that no one has ever noticed this unbridgeable gap between the treatment community’s diagnosis and understanding of alcoholism and the sole model of recovery it suggests.

The point is not to engage in argument with AA or its members; rather, the point is a psychological, medical, economic, and political one: Why is AA never questioned as the sole road to recovery by those who so depend upon it when “treating” patients? Why has no one else ever noticed the black hole between diagnosis and “treatment”? How can the treatment community not notice that AA’s primary document stands in direct opposition to its own accepted definition of alcoholism?

The American Medical Association’s own diagnosis states: “Disease means an involuntary disability. It represents the sum of the abnormal phenomena displayed by a group of individuals. These phenomena are associated with a specified common set of characteristics by which these individuals differ from the norm, and which places them at a disadvantage” [again, bolding and italics mine].

The American Psychiatric Association never mentions AA in its Substance-Related Disorders Position Statement. Its Diagnostic and Statistical Manual of Mental Disorders describes only criteria; it no longer addresses etiology in regards to any disorder or, in the sole case of alcoholism/addiction, “disease.”

Despite this avoidance of the issue at hand, the American Psychological Association, the American Psychiatric Association, The American Medical Association, and The World Health Organization all consider alcoholism a disease. And to prove how the medical community and AA are becoming still more integrated, some medical schools are now including AA “education” as part of their academic requirements.

What does all of this mean for the patient? Isn’t the treatment of a disease the role of the treatment community? Or is the treatment community’s addiction to AA psychological, so that it refers patients to the most available “resource” as a stress reliever? Is it economic, since AA is free, much like church? Is it political, with “disease” more likely to gain legislative support that in turn provides funding for research, grants, etc.? Is it simple ignorance? Going back to the patient, left to a cold war of the self, the answer hardly matters. However, were the treatment community to recognize or admit the discrepancy between its diagnosis and treatment of alcoholism, it would make all the difference in the world.

In conclusion, given the treatment community’s ubiquitous acceptance of alcoholism as a disease and acceptance of AA as the sole recovery model for alcoholic patients despite AA’s insistence that alcohol is the result of “character defects,” the entire psychological, psychiatric and medical communities are not only complicit in the inevitable relapse of patients but engaging in nationwide malpractice.

I will start by giving the straight facts about AA. The program helps many, and adherents attribute their sobriety to it. I take them at their word. As I see it, whatever works, works. Nevertheless, AA is clearly a religious organization, steeped in Christian theology, with many of the meetings subtly reassuring the nonbeliever that he or she will, in time, come to pray on their knees, as I was so often told.

This approach is underpinned by the Big Book chapter entitled “We Agnostics.” It relates the central AA message: The group will accept atheists and agnostics, but unless they eventually accept a higher power known as “God,” failure is guaranteed. “Actually we were fooling ourselves,” the chapter asserts, “for deep down in every man, woman, and child, is the fundamental idea of God. It may be obscured by calamity, by pomp, by worship of other things, but in some form or other it is there. For faith in a Power greater than ourselves, and miraculous demonstrations of that power in human lives, are facts as old as man himself. We finally saw that faith in some kind of God was a part of our make-up, just as much as the feeling we have for a friend. Sometimes we had to search fearlessly, but he was there. He was as much a fact as we were. We found the Great Reality deep down within us. In the last analysis it is only there that He may be found. It is so with us.”

The same chapter later relates a story in which an alcoholic asks himself, “Who are you to say there is no God?” That, indeed is the question, or one side of the question. I might just as easily say, “Who are you to say there is one?”

The Christian roots of the AA program are well documented and continue to bloom in its Edenesque garden. I need not repeat the evidence here. It is not my duty to condemn or refute AA.  Rather, I wish only to warn agnostics and atheists that — after the short honeymoon — they will not be accepted by the program unless they accept its language, which irrefutably cannot in any way be interpreted as secular. Just as an atheist and a fundamentalist Christian would be unlikely to maintain a successful marriage, so the atheist and AA are unlikely to form a lasting bond. Exceptions exist, but the AA atheist or agnostic has a big house to build in order to house that much self-delusion.

I shall write from my experience. After much well-meaning advice from friends seeking to help me overcome my hesitation to join AA due to the “God factor,” I thought I had finally found a way around the problem of what exactly my “higher power” would be.  It would involve the infinite universe and the nothingness atheists, especially, and, to a lesser degree, agnostics, face. I would give myself over to nothingness, “turning over” my problems and thereby finding a faithless faith.

More than anything, I sought comradeship.  I found it, at first.  The key to the AA meeting is the common bond between all addicts and alcoholics.  I do not dispute that this is helpful. Indeed, AA could start and stop with that assertion, providing a truly all-inclusive safety net. However, as in all movements, the initial idea of AA was quickly reduced to dogma and a reactionary stance.

I began with the intention to find what I needed and leave out what I didn’t. I discovered what I needed at my first few meetings, which was the simple sharing of common experience.  But during the fifth meeting, the 11th Step was discussed. “Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of his will for us and the power to carry that out.”

While the words “as we understood Him” are often used to support the contention that AA members can believe God to be anything at all, the discussion revealed every single member as understanding God in the very same manner.  All had always believed or later came to believe in a Christian  God.  All had fallen to their knees and prayed. Others nodded their assent.  Oddly, every member understood prayer, but many could not grasp the idea of not praying: Does not compute.

When my turn to speak arrived, I simply restated that I was an atheist.  I threw the bone that I “may change my mind — who knows? — but that’s how I understand things now. I don’t see why this stance should discourage me or anyone else from seeking help here.”  I wanted to add, “By the way, I can teach the basics of meditation in ten minutes,” but I left it there, not wanting to be reprimanded for starting a philosophical debate.

My message was met with weak applause and a few askance glances. “Here,” I thought, “comes the first argument.”  The honeymoon was over.

Immediately after the meeting, I was twice pulled aside and told that I would come to find what all the others had found.  It seemed I must find it, since they had found it.  Just as I find it incomprehensible that anyone believes in a benevolent God, so they find it incomprehensible that anyone doesn’t. I could point to the Holocaust and say, “That event caused many survivors to lose faith or even conclude that God must be evil.  Isn’t that rather strange behavior from a God expecting so much attention?”  They would point to me and say, “You may go, but you’ll come back when you hit bottom again.”

Now, I must give AA its due. Through discussions not involving God, I was able to see how I had undermined myself via self-deception. This was certainly an accomplishment for which I thank AA. The problem, then, begins and ends right there. For me, such discussions were enough. Leaving God completely out of the program would allow anyone to benefit from it. Replacing faith in a higher power with the acknowledgment that the mind cannot always be trusted would achieve similar results.  No one would be excluded or made to feel they were violating the basic tenets of what amounts to faith.

I relate this to a short fling I had with Catholicism.  This occurred in my early thirties.  I found a way around every aspect of Catholicism with which I did not agree.  I discovered authors like Graham Greene, who seemed to harbor so many misgivings regarding the Church that it was nearly impossible to categorize him as Catholic. Graham himself claimed that he was a “Protestant within the Church.”  I had reached a different conclusion: “I am a Catholic even if there is no God.”  Irrational as this claim may seem, I was quite satisfied with it and myself. Eventually, I lost my ability to trick myself around the sticking points of Catholicism and my own “clever” argument.

Just about then, the child abuse scandal broke, and with it my faith finished collapsing.  It had been waiting to fall, and reassurance that the guilty priests proved the exception to the rule of good priests failed to convince me that I could, or should, restore a bridge that would crumble into the river below regardless of repair.

For AA to work, one must either completely accept its basic tenets or find some way to believe its central proposition despite one’s rejection of it, just as I had done near the end of my Catholicism. I am glad that some are able to do the latter, for many maintain sobriety within the program.

Others, like myself, may be as humble as any Christian and believe in transcendence (a scientifically proven phenomena, i.e., a literal state of mind provable by brain scans and other methods).  However, we cannot trick ourselves around praying, nor fail to detect the contradiction between AA and what we disbelieve. We cannot say, “We are not religious but spiritual.” We cannot accept the view that anyone, anything or any force watches over and protects us.

In short, those finding a home within AA meetings do well to make their beds there.  Those finding the same beds uncomfortable should resist complaining to the hotel manager and simply depart. If that person insists upon complaining, the manager will state that the traveler “shall find no better bed in the world, and you should thank God on your knees for having such a bed. Why, if you leave, you’ll come back. Until then, enjoy sleeping on beds of nails and knife-like rocks. You’ll be back, all right. You’ll return to see that this is the best and indeed only bed in the world.”  Such a traveler may remain a traveler; better to keep moving than fool oneself that a place in which one does not belong is the best and only place in the world.