Friday, May 26, 2006

Let Us Now Praise Obscure Men

The secret about addiction recovery that began to be revealed 71 years ago on June 10, 1935 in Akron OH (when Bill W. gave Dr. Bob his last drink to steady his hand during an operation) is twofold. Recovery comes through one addict talking to another, and both of them need to work at achieving what the old-style members of Alcoholics Anonymous called "ego deflation at depth."

The Twelve Steps are the means of the latter changes and form the basis of the former conversations.

The psychiatric model of addiction treatment is about as successful as the cold turkey, or Mao's "We will shoot you" methods; namely, hardly at all. The Twelve Step model has been shown to have the greatest success rate, but it is still in the range of 10%. Ten percent of the people who come in the door recover for more than five years.

Since roughly 10% of the population is addicted to alcohol or pharmaceuticals, out of 300 million Americans 30 million are addicts (higher if you count tobacco.) Twelve Step (AA and Narcotics Anonymous) membership is under 3 million. Probably something like 5% of addicts recover at best, lumping undocumented individual effort and psychiatry in with the Twelve Step programs for the moment.

But something has to be done. The enormous majority of people addicted to alcohol, tobacco or pharmaceuticals die of their addiction, and die earlier than their cohorts. The human cost to children, spouses, families, friends and co-workers is vast, and the economic cost is hardly trivial either.

Thus even the relatively ineffective treatment models of psychiatry and clinics must be pursued until the human mind evolves a better course. The American Medical Association adopted the disease model of alcoholism in the early 1950s; AAs say the disease is mental, physical, and spiritual. In either case, addiction is an income-level-neutral killer and a public health menace greater than automobile accidents, AIDS and cancer combined.

The Twelve Steps are voluntary and based on self-diagnosis. "If you think you have a problem, you have a problem." Many psychiatric conditions, such as bi-polar and depression, substantially overlap the addicted population and render treatment more difficult, the Twelve Steps less accessible. Such diseases hinder or even prevent achievement of the level of emotional honesty required for successful Twelve Step work.

The charge of religiosity is often leveled at Twelve Step programs but results from a simple confusion. Religion is to spirituality as marriage is to sex: an attempt to institutionalize that which we all know to be wonderful. The Twelve Steps require an acknowledgment of a spiritual dimension to mankind's actions but specify neither the nature of any godhead nor the practice of any belief.

Far from discouraging personal responsibility as is often charged of the psychiatric model, the Twelve Step model cannot work without an early, and frequently repeated, influx of self-awareness as to consequences of one’s actions. And it is probable that the charge against psychiatry of enabling victimization is the result of exaggerated attention to one phase of psychiatric treatment without regard to those which precede and follow it.

Quasi-punitive, “Just butch it out,” attitudes toward addiction recovery are, however well-meaning, wholly counterproductive with individual addicts. Moreover, this approach inherently dooms any course of public policy that is based upon them.. In fact, it smacks more of religiosity (of Puritan Jonathan Edwards’ 1741 Sinners in the Hands of an Angry God type) than do the Twelve Steps.

In correspondence with Bill W. in the late 1930s, Karl Jung wrote tof his experience of chronic alcoholics in his Vienna practice. They were completely incurable, wrote Jung, until they had undergone a spiritual transformation. Then they had not only hope, but a means of going forward without daily doses of the substance that was killing them.

The Twelve Step rooms appear, empirically, to be more successful in inducing the amount and type of spiritual change necessary for altered behavior patterns than do the churches. To be fair, the churches are not really in the business of acting as agents of change, their original message having become dulled by time and dispersed by human slovenliness. Perhaps the same will be true of AA by the year 3935.

But in the mean time it does no good to blame either society for permitting, or the individual addict for adopting, the use of mind-altering chemicals (regardless of delivery sytem.) Lily Tomlin’s joke is also true in reverse: “Reality is for people who can’t handle drugs.” Since there is little commitment whatsoever by business or government to the notion of improving reality, we have to work on people instead.

Psychiatry, treatment centers, clinics, Twelve Steps: no expedient is too shabby, nor is the cost of it too high, to be pursued in order to help individuals and society deal with the scourge of addiction. Use the shotgun method. Fire both barrels.

Just don’t stand around saying, “You missed,” as if that were a helpful rather than an inevitable observation.

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