Addiction and the role of behavior
Recently I've seen data that talks about the success rate of rehabs and 12-step programs. The data is all over the place. Individual rehabs will cite rates as low as five percent, others about 17 percent, others about 30 percent. "Old" Alcoholics Anonymous makes claims of 75 percent; modern AA indicates success rates are far less. Some suggest, and have evidence, that the "success rate" for AA is about the same as trying on your own.
To which I say: If you're an active addict studying the success rates of recovery, you're asking the wrong question. What you're doing, even if you're following the right logic and are utterly right on the facts, is bullshitting yourself. This is one of the most difficult concepts to explain to people. You can be absolutely right and still dead wrong.
Some criticism of treatment programs discuss flaws in the disease model of drug and alcoholic addiction. These say the key issue is "choice."
I have 18+ years of sobriety after a nine-year run with alcoholism, and I think I know something about this subject. My answer — there is no question that alcohol and drugs use at frequent or high levels can impact your thinking in dramatic ways, and deeply impinge your will to make further choices. Whether you want to call this result a disease depends on your definition of disease. Call it Fred if you like. (No actual Freds were harmed in the writing of this post.)
I'll say this much: Alcoholism and drug addiction are not diseases in the sense that influenza or malaria is a disease. And Alcohol and drug addiction do not respond to "treatment" the way a doctor would treat influenza or malaria, either.
That said, I believe that while the brain and the mind are not exactly coterminous, they are pretty clearly connected, and whatever the "mind" does in this life is done through the brain. I don't care how mystically enlightened you are — in this life, if you've got a brain problem, you've got an ensuing mind problem.
And addiction is a mind problem that becomes a brain problem that becomes a mind problem. See, mind impacts brain — your brain rewires itself based on stuff your mind does. If you want to call this mind-brain-mind-brain problem a disease, you're welcome to, IMHO. If not, fine. If Fred, fine. Define things as you'd like.
Whatever you call it, "treatment" for addiction is vastly different than other medical treatment. Some "treatment" programs focus on this purported gap between the brain and mind, otherwise known as spirituality. This is clearly different from taking penicillin for an infection. "Treatment" for addiction involves re-establishing a person's choice. To me, "successful treatment" of addiction means the person has a restored volitional capability to choose to use the substance or not UNDER NORMAL AND ACTUAL CONDITIONS OF THE "TREATED PERSON's" LIFE. People subject to abnormal amounts of structure and support, for example, may temporarily recover the power of choice. Similarly, people subject to grave threats may do the same thing. That's irrelevant to me — the key is under the person's actual life conditions, do they have a restored power of choice to use or not when undergoing this or that program of recovery?
But isn't that an unscientific question? That's why I think the studies of recovery rates are irrelevant — it's not about what people do with their choices, it's that they have a real choice. I'm dubious about social science in general, but that issue of choice is a question that an individual, and an individual only, can answer: I have undergone this "process" or whatever, and do I have the power to choose to NOT use/drink in my normal daily life?
Some AAers will say, yes, I have the power to choose, but only if I move my own power to choose on this topic to a Higher Power, that is, to that gap between mind and brain. Fine. I do that myself, and it works great for me when it comes to booze. Indeed, an essential part of recovery was when I recognized I always had a choice. To those who speak of the disease-model of recovery as not involving choice simply don't understand AA or what it teaches. Choice is crucial to AA.
But the problem is we have a tendency to think of "choice" as involving a mental act only, an abstract decision-making thing. "I shall wash my car today." Will you wash your car? I don't know. You may be the sort of person who decides and does? But you may be the sort of person who says, "Ah, I'm feeling blue right now, and I want some ice cream instead." Or you may be the sort of person who says, "I tried to wash my car, but we're out of soap, and it's too much of a hassle today to go get more, so I will not wash the car today."
What AA, and healthy cognitive psychologists will tell you, is that there are three main components to thinking: what we might call our rational side, our emotions and ... drum roll ... our behavior. Behavior is crucial to our thoughts. Our brain rewires itself based not only on what we think and what we feel, but what we do.
What AA tells you is this: Your ability to choose NOT to drink is deeply impaired. That's because your thinking is impaired, especially in two of the three crucial areas, the rational and the emotional side. Those who do not recover are those who try to reason their way to the choice not to drink, or those who try to rely on emotions to give them the strength, such as moments of great inspiration — invariably, it's a temporary victory, and goes away when one returns to the normal conditions of life. We in AA do not know why this is so, and we do not know what you want to call it (yes, call it Fred if you like, we only know based on our own experience that two-thirds of what goes into our thinking cannot help us in this volitional area.
However, we still have other choices we can make. We may not be able to choose NOT to drink, but we can choose to do other things. We can choose to go to a meeting. We can choose to pray. We can choose to avoid people, places and things that put us in danger of drinking. We can change our normal conditions of life to make our choice not to drink more easily. We can get a sponsor.
Soon, we in AA discover that not only can we assist our decision not to drink based on our behavior, but we can strengthen the emotional side. We can "share" our emotional pain at meetings, and receive love and support, thus temporarily relieving that pain. Thus, our thinking improves in two areas.
Some of us continue to strengthen the "rational" side as well. We know that we need to use our reason to guide our behavior and our emotions. Reason is still in the driver's seat. But we in AA don't say, "I will not drink for the following reasons ..." Instead, we say, "I will do this and that in order to improve my odds of recovery, and I will avoid x and y." We say, "I will attempt to deal with emotion x by behavior y." We say, "I will call my sponsor when I have the urge to drink, rather than argue with the desire until it becomes a major urge." We don't run straight at the abstract choice of not drinking, if we can avoid it.
And yet we may still face a moment when the only thing stopping us from drinking is the movement of our arm. Even then, we do not argue with the reasons (it will be twisted if we've gotten to this point) or with the emotions (similarly twisted). Instead, we will recognize that we can choose to move our arm (which is a behavior) or we recognize we may choose to get up and go elsewhere, call our sponsor or other AA friend, and then begin better behaviors that do not let us to this kind of emotion-shattering moment. Addicts who recover find they behave their way to better thinking, which in turn leads to better choices. (Keep in mind the emotional side of things complicates this process.)
At least, that's how I look at it. Is addictive drinking and drug use a choice? Yes. Is it a disease? Depends what you mean. What is treatment? Re-establishing choice. Does "choice" mean, "I decide x, and thus x happens?" No. It means choosing behaviors and coping with emotions that impact your thinking in positive ways, enough to live out your goal not to drink.
And all this gets lost in studies on recovery rates.
UPDATE: By the way, I was thinking about the role of honesty in "treatment." AA has a statement that only those who are incapable of being honest fail to recover. As harsh as it sounds, I believe it to be the absolute truth. And here's why: The addict tends to be dishonest in one key area of thinking — and that's the decision to act instead of think or feel. The AA recovery program requires you to be honest enough to do the required behaviors instead of relying on your own rational thinking or emotions to get rid of an unwanted desire.
It also involves being dishonest about behaviors that lead to drinking, as well as dishonestly ignoring thoughts and emotions that lead to drinking.
For example, if I feel crappy, I know that I need to DO something. Talk to someone, or help another, or get out of isolation, instead of trying to correct the emotion on my own or try to reason my way out of feeling that way.
That is, if I want a friggin' drink, I want a drink. If I am honest with myself, I know I need to do a behavior right then, and everything short of a behavior is dishonest lying bullshit. Addicts who don't recover (and want to) are those who aren't honest enough at this moment — they lie to themselves about the need to act. Instead, they try to think or emote out of the process. And eventually lose.
UPDATE 2: Also, by the way, the focus on honesty is one reason Theodore Darymple thinks addiction "treatment" and medical treatment are two different things. You can be as dishonest as you want, but if you take your antibiotics for an infection, you'll get better. Unless you lie to yourself about taking the meds, but that would be too weird ...