Just how irrational is AA? Reaction to Glaser`s article

I've  just read Gabrielle Glaser's Atlantic article entitled, “The Irrationality of Alcoholics Anonymous,” for the third time. With a master's degree in history from Stanford, experience as a writer in upper echelon publications, Glaser,   describes herself as an award-winning journalist. She  is also the author of Strangers to the Tribe: Portraits of Interfaith Marriage, The Nose: A Profile of Sex, Beauty and Survival, and most recently Her Best-Kept Secret, Why Women Drink - And How They Can Regain Control.

Glaser attacks Alcoholics Anonymous (AA) as an ineffectual, nonscientific, outdated approach to alcohol treatment,  that has nevertheless managed to dominate the field and in the process, prevent many people from getting the help they so desperately need.  Glaser strongly advocates for the use of pharmacological approaches to  treatment and argues that abstinence-based models may actually  stand in the way of treatment for many individuals with alcohol use disorder. She seems especially enthralled with the notion that many people can learn to moderate or control their drinking--a controversial approach, but one that is not lacking in scientific evidence.

I found myself agreeing with almost everything she said, but I still didn’t feel comfortable with what I was reading. Maybe I'm paranoid, but at times Big Pharma seemed to be lurking in the background.   Maybe that's why I had to reread it.  I did love   her line that Minnessota is known as "The Land of 10,000 rehabs."

Okay already, AA is not a panacea, and it is not for everybody. Most people in the behavioral health field have known for decades that many AA groups--with their aversion to medications, confrontive methods, and reliance upon spirituality--are not appropriate for many patients. I probably wouldn’t suggest sending a person with schizophrenia, a teenager just experimenting with alcohol, or a rabid atheist to AA. Penicillin, for example, is not   ineffective or  a bad medicine just because a lot of people are allergic to it and may have a bad reaction.

In journalism, however, if you want to draw attention to yourself, the most surefire method is to pick a fight, as it is conflict that sells and attracts readership. The AA community, if there is such a thing, is certainly a worthy adversary, given the vast number of members, groups, and people who claim to have benefited from it.

Glaser seems dismissive of personal testimonials in support of the efficacy of AA, preferring instead to rely upon some idiosyncratic research about AA recovery rates and Cochrane Reports that assert an obvious lack of scientific evidence to support AA.

On the other hand, she has no problems with personal testimonies regarding how AA has  harmed individuals, prevented them from getting the help they needed, caused them to relapse, or, in her own case, how effective naltrexone was in curbing the pleasure she received from a glass of wine.

At times she seemed like the movie critic, who criticizes a movie for not being what she thought it should have been, rather than reviewing it for what it is.  AA is not an evidence-based treatment, never purported to be one, and given its basic structure, probably will never achieve that distinction.

There also seemed to be some statisical sleight-of-hand regarding  outcome measures. The AA success rates she presents is actually much lower than the rate for spontaneous recovery, without any treatment at all, which she cites elsewhere.  This suggests  that AA must have a very significant negative effect on most people's effort to recover, which seems unlikely.

The random sliding criteria also seems to apply when it comes to what she defines as success in alcohol treatment. She says that AA has single digit success rates  in attaining abstinence, while naltrexone, as used in Finland has a 75% success rate in helping people moderate  their drinking. Although I thought I read that moderate drinking is sometimes defined as three stiff ones a day. From a harm reduction perspective, I suppose that is progress, but I’m not sure that’s sobriety either.

Glaser also seemed overly concerned that, since parity and the Affordable Care Act will lead to increased coverage for substance abuse treatment, that somehow these funds  are going to be squandered on non-evidence based AA type services. This is is odd since AA doesn’t charge any fees. I for one wouldn't worry about the pharmaceutical companies getting their fair share of the "Obamacare" pie. I  would worry more that manage care companies will misuse AA, and not because it always results in such great outcomes, but because it doesn't cost them anything.

It is sort of the same way they tried to hijack drop-in centers and clubhouses as a substitue for day treatment and partial hospitalization programs in Medicaid capitated  payment programs.  It is true that many rehabilitation programs (both for-profit and not-for-profit)  incorporate 12-Step programs as part of their treatment and especially aftercare, but for some time the trend has been toward the use of evidence-based practices. In the public arena, the SAMHSA evidence-based registry of interventions is de rigueur, when applying for funding or grants. I may be missing something, but I just don’t see AA as being as monolithic today as Glaser portrays.

I personally have seen 12-Step programs be very successful with patients when nothing else had ever worked before. There is no doubt in my mind that AA can be highly effective for some people. Arnold Lazarus once wrote in regard to technical eclecticism that therapeutic effectiveness depends upon an array of effective techniques, rather than a mass of plausible theory. AA is simply one of these techniques. Regardless of how it actually works, it seemsvery effective with a certain population and why deny this opportuity to them?

I also agree with Alabama physician W. Roger Carlisle  who commented on the article saying, “… she has the wrong target. AA is a fellowship and a community that offers support and emotional healing for people and families that have been ravaged by the disease of alcoholism. It obviously works for its members in its over 97,000 practicing groups.” I would suggest that for many people, AA provides the structure and narrative for personal recovery and a folk support system that allows them to develop an effective ideology of change.

Finally, I believe Glaser has provided a real service in bringing to the public’s attention the variety of effective treatment options that are currently available, especially the medication-assisted treatment  approaches that can help reduce cravings. Help is out there. She made me want to run out and immediately see how many of our patients, who have alcohol use disorder diagnoses, are currently being prescribed  acamprosate, naltrexone,  or Vivitrol, the injectable form of naltrexone (There are a lot more than I guessed it turns out).   

She also scores high points for arguing about the need for better certification and credentialling for addiction service providers. In many ways her attack on AA, however, seems superfluous to these  important messages, but without it there would probably be no headlines or television interviews. I would also suggest that the ultimate fate of AA remains where it belongs, in the public marketplace of ideas and  interventions.