After the phone screening, the patient was scheduled for admission and arrived as planned. The initial evaluation and consent process went fine, but it did not take many days on the unit before she began to have issues with some of the community rules. Now, maintaining the structure of everyday life on a treatment unit is challenging on the best of days. People come in with complicated problems, in different stages of withdrawal, and with very different backgrounds. They all need attention to different things, many of those very private in nature. Yet for a short time, all patients also become members of a small community. They can draw strength from one another, but there can also easily be frictions. That kind of community is hard enough to keep running smoothly in a regular treatment setting. Imagine, then, the challenges of combining that task with repeated blood sampling, psychological evaluations, brain scans, and other research procedures. Bringing all that together and still having a good treatment environment is complex beyond my imagination. I truly admire the dedicated nursing staff in our program that makes this work every single day, month after month. It is largely a mystery to me how they do it. But both the treatment and the research get done. And it seems that most of the time, there is the right balance between structure and a friendly, caring atmosphere. Conflicts rarely rise above whether someone just back from a research procedure should be allowed to turn on the television while other patients are still in a treatment group. And those conversations, too, tend to end with a joke and a smile.
So here we were. Like most places, our treatment groups were shaped after the principles of “twelve-step facilitation.” Although made more generic than the original, this is an approach to treatment that is firmly rooted in the Big Book of Alcoholics Anonymous,2 all twelve steps of it. Famously written by William Griffith Wilson (“Bill W”) and Dr. Robert Holbrook Smith (“Dr. Bob”), the Big Book may be under your radar if you have not been exposed to the addiction treatment scene. But as a treatment manual its popularity will surely never be surpassed. Since it was first published in 1939, it has sold over thirty million copies, making it one of the most widely disseminated books of all times, alongside the likes of the Harry Potter series and the Bible. All these years later, this is a book I personally still find to be amazing reading. It is earnest, brutally so at times, such as in the chapters “Bill’s Story” and “Dr. Bob’s Nightmare.” It is, given that the better part of a century has passed since it was written, brilliantly insightful about many of the fundamentals of addiction. This is perhaps most striking in its framing of addiction as a disease, one that is chronic in nature and associated with changes that for life make most patients vulnerable to relapse. Hence the principle that “once an alcoholic, always an alcoholic,” and the conclusion that only lifelong abstinence can lead to recovery.
3 Besides all the specifics, I find the Big Book quite heartwarming. After all, its fundamental concept is that by joining a fellowship, people can help one another overcome alcoholism and the adversity that comes from it. What is there not to like?
Because of the devastating natural history of alcoholism and the lack of effective medical treatments at the time, Silkworth and the founders of AA had to seek hope in something outside themselves, and outside professional treatment. Similar to countless men and women facing various kinds of adversity in prescientific times, they found it in a higher power. In the case of AA, this is a concept that should be understood very broadly. Compared to most organized religion, the Big Book and the AA movement as a whole are a marvel of tolerance and open-mindedness. They do not favor any specific congregation or religion, and they welcome everyone who wishes to join. But make no mistake: for AA, the key to successful recovery lies not primarily in understanding the addicted brain in scientific terms and then using that understanding to help the brain’s owner recover control of his or her life. Instead the only hope for recovery is seen in admitting defeat and transcending the failings of the addicted brain by turning to the higher power. For those unfamiliar with them, let’s take a look at the twelve steps of AA, which encapsulate this thinking and remain the basis for the movement.
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. 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.
12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs
One would be hard pressed to find any aspect of this message offensive. But it is also hard to escape its spiritual, rather than scientific, focus. More than half the steps directly speak of a god, a godlike power, or prayer. For starters, that is clearly not for everyone. But that is not necessarily a problem, as long as people for whom this is meaningful and appealing benefit from participating. The question is, then, how do we select those people, and what are those benefits? The answers to these two key questions need to be viewed in the context of a widespread American perception that twelve-step programs are the standard of addiction care.
Furthermore, even assuming that these outcomes are better compared to not participating, the surveys do not allow us to disentangle what is causing what. To what extent do outcomes that are reported actually reflect effects of AA participation? To what extent are they the result of the fact that people who are better able to stay sober in and of themselves are also more likely to stick with AA? “Really tried” has in the AA surveys often been interpreted as sticking with participation for at least ninety days. But analyzing the data that way brings up a classic problem that evidence-based medicine has had to deal with in all areas of clinical practice. This kind of “completer analysis” has a well-known source of error: it selects people who had inherently better chances of achieving good outcomes anyway. Imagine if you were treating cancer but included in your analysis only people who completed a one-year course of treatment. If people who did not get included had all dropped out because they had a particularly malignant form of the disease and were in fact dead by the one-year follow-up, the outcomes for those who remained in treatment for a year would look great! The same, of course, applies if people with particularly hard to treat addiction relapse within the first three months and drop out of AA participation.
Finally, even if we were able to detect beneficial effects of AA participation in a valid manner, it would be hard to know to what extent they are the result of following the twelve steps. There is no obvious way to distinguish that possibility from generic effects of being in a group of supportive people who share one’s experience as well as one’s goals, and who encourage one to stay sober. Maybe joining a chamber orchestra of recovering alcoholics, practicing Baroque music a couple times every week, and having a festive but alcohol-free meal together on the weekends would be just as good? That is how one of my hardest to treat patients, a university professor, finally achieved stable recovery. But I will never know what in that mix that did the trick. It would be difficult to demonstrate the specific influence of the chamber orchestra participation, the music that the group played, or the Sunday dinners. Or maybe the patient had just reached the point in life when he would have sobered up no matter what, and that in turn enabled him to join the chamber orchestra. Who knows? An individual life is an experiment run without controls.
With these observations in mind, it should not be entirely surprising to read the “Plain Language Summary” of a large meta-analysis published in 2006 by the International Cochrane Collaboration, the gold standard of evidence-based medicine:
All in all, this lack of reliable evidence for clinical benefits, obtained through scientifically valid methodology, would be devastating if we were evaluating a professional treatment. It would be worse still if patients or the taxpayer collective were being asked to pay a great deal for it. But neither the former nor the latter is the case. Enlightened AA members would be the first to point out that theirs is not a professional treatment that has as its objective to replace other treatment options. Instead it is simply a fellowship of addicts and recovering addicts who are willing to support each other in achieving and maintaining recovery. There is a mantra that has a lot truth to it: AA is everywhere, and it is free. As such, AA may really be outside the scientific medical paradigm. It does not lend itself well to the type of evaluation that is at the core of evidence-based medicine. In a sense, then, if we view the AA movement appropriately, the data may not be all that critical, as long as AA is not confused with professional treatment.
The bottom line for me is this: achieving recovery from addiction is a daunting task. For a long time, professional medical or behavioral treatments had essentially nothing effective to offer for this devastating disease. To date, treatments that have emerged are with a few exceptions only modestly effective.6 Even as these treatments improve, people will continue to need support outside the professional treatment setting in order to live lives that are both worthwhile and free of alcohol and drugs. As long as we can work together, communities of people that vouch to provide one another support in staying sober and drug free surely should be a great complement to professional, evidence-based treatments. Perhaps the only valid criterion for whether these mutual-help groups are valuable is whether the people who participate in them feel that they are. When that is the case, we should encourage patients to seek them out. It is much like someone who is overweight, has developed type 2 diabetes, and decides to join a church that promotes a healthy lifestyle, or the Sierra Club and its hiking group. If the patient feels that this is helpful, then we should support him or her to stick with it, while at the same time tightly managing the metformin prescriptions and controlling blood sugar. Clearly AA is a major resource where countless patients find support for a drug-free life. It should be equally clear that, because of its spiritual focus, AA is not for everyone. Other options may be a better match. The same enlightened AA member who points out that AA is not a professional treatment would probably also agree with me in this: while the AA fellowship welcomes everyone with an addiction, it may not necessarily be
for everyone with one.
So over my years in the field, I have taken a pragmatic approach to the tensions that may arise between medical treatments and AA participation. We, meaning the medical profession, do the best possible, science-based medical and psychological treatments currently available. We also work hard to develop new methods. At the same time, we happily introduce or reintroduce patients to AA, a resource we know many have found to be helpful in trying to achieve and maintain recovery. Some patients come back from their first AA meeting and describe an immediate feeling of having found a home. For many among our patients, with broken families, lost jobs, and lives filled with numerous challenges caused by their addictions, that is a big deal. Finding that kind of home may turn into a lifelong source of support. But other patients instinctively turn around in the doorway. There are many reasons why AA may not be for them. Or maybe they just do not feel like they belong, without being able to put their finger on why. That too has to be respected. In those cases we try to find other ways to support and manage long-term recovery. It is really that simple, at least in theory.
By the end of our meeting, which lasted almost an hour, I was convinced we had both learned something. I offered to see the patient for a couple of follow-up appointments. She considered my offer of a naltrexone prescription but decided to try and stay sober by sheer power of will. I suspect that by then she may well have succeeded out of pure spite. I let her know I hoped it would work out, but also that she was welcome back if it didn’t. At least it felt like we had worked out the issues that had upset her. After she left I gathered my staff and reinforced the principles I have outlined above. I charged them with creating a better distinction between what we do as medical professionals and what we support our patients in doing as self-help. I also charged the staff with developing alternative behavioral treatment options to the twelve-step facilitation groups so that all patients would have choices available to them that they could feel comfortable with. With that I thought things had been resolved in a way that had offered us all opportunities to grow.
I was getting ready to argue. I was considering resigning. Fortunately my boss helped me get over it. A wonderful internist, he had grown up in Hungary and somehow always managed to cope with madness by cracking a socialist era joke. We found a compromise solution, emotions cooled off, and we were able to stay focused on our mission. These are not easy issues, nor was this the first time they were debated. Already in 1999, the U.S. Court of Appeals for the Second Circuit ruled that an atheist drunk driver’s constitutional rights were violated when he was forced, as a condition of probation, to participate in a “religion-tinged Alcoholics Anonymous program.” This triggered a fair amount of debate within the AA community. Although there were clearly two sides to the debate, many AA members felt that forcing people to participate runs counter to the core idea of AA the way they know it: a voluntary fellowship of people intent on supporting each other in recovery. I agree and in fact can’t see how any other position could be defensible. And I can’t see how advising patients to discontinue or avoid medications their doctor has recommended based on solid evidence can be defensible either. I hope that these are marginal phenomena or will become so with time. Meanwhile, I will continue to advise patients to try out AA and see if it is for them. My responsibility as a physician will remain to make sure patients get the best treatment data support, whether they feel spirituality should be part of their recovery or not.
Based on these principles, Anderson’s model was first developed at Willmar but continued to evolve to maturity at a location about 140 miles to the east, in Center City, Minnesota. This was the location of a farmhouse by a lake, donated by a benefactor in 1949, where things were started off by a staff of three, operating a guest house for alcoholics, with a daily headcount of less than ten. The guest house was not a treatment institution in any traditional sense of the word. The accounts of those days say that there were only a few set elements of daily life, and those would not typically be viewed as professional treatment. The guests were “simply required to behave responsibly, attend lectures on the twelve steps of AA, talk with the other patients, make their beds, and stay sober.” Although this may not sound all that significant, these were the rather humble beginnings of the Hazelden Foundation, and what ultimately became the Minnesota Model. Fully developed through the 1960s, this model spread through the United States and the world in the 1980s and became that most widespread model for addiction treatment worldwide. Well-known addiction treatment centers, including institutions such as the Mayo Clinic and the Betty Ford Center, are patterned after the Hazelden model of care and in fact had help from Anderson and his coworkers in starting up their work. Anderson moved from Willmar to Hazelden full time in 1961 and remained active there until his death in 2003. He first was vice president, then president, and then president emeritus and is essentially the founder and the main architect of the Minnesota Model.
Indeed, the research that had earned us the award seemed quite removed from the core elements of the treatment traditions from which the Minnesota Model has grown. In a paper published in the journal Science, we had gone from a genetically modified mouse model to an experimental study in patients with alcohol addiction and made findings that could possibly represent the discovery of a new alcoholism medication. The emphasis, of course, should be the word “could.” When it comes to diseases of the central nervous system, no matter how good things look at the early stages, only a very small fraction of new medications pan out in the long run. The brain and its behavioral disorders just seem to be difficult targets. After a golden era that culminated around the time of the introduction of depression medications Prozac and Cymbalta and the antipsychotic Clozaril, successes have been few and far between. Because of low return on investment, major pharmaceutical companies have over the past years pulled out from psychiatric disorders one by one. In addictive disorders, their interest had not been all that great to begin with.
But it was the brain-imaging data that convinced me we may actually be on to something important. Together with a team headed by my colleague Dan Hommer, a fellow psychiatrist and the person from whom I have learned much of what I know about brain imaging, we studied the effects of the new medication on brain responses to positive and negative emotional stimuli. Dan and his group had previously shown that the brains of alcoholics overreact to negative emotional pictures, right in the brain areas known to process negative emotions. Teaming up with Dan’s group, we saw the same highly reactive emotional responses in our placebo-treated study subjects. In contrast, patients treated with the experimental drug did not respond with any such activation. That was exactly what we had hypothesized and hoped for.
I was to receive the Anderson Award at the annual conference for the National Association of Addiction Treatment Providers in Florida. Carlton Erickson from the University of Texas-Austin, a member of the award committee and an expert on communicating the science of addiction to laypeople, had kindly provided me with comments and suggestions to tailor the talk to the intended audience. With his help I worked hard to avoid the two most common traps that a passionate scientist can fall into on an occasion like this. First, I tried to zoom out from our own research and provide as much as possible of the big picture of developing medications for alcoholism. When talking about the specifics of the things we do, I tried to put them in that broader context. Second, I cut out as many nonessential technical details as I possibly could.
Two years later I had finally decided to write this book. Presenting the science was going to be challenging enough, but that is after all my job. What I knew I needed help to understand was the gap between what science tells us about addiction and its treatment, on one hand, and the industry that seems to provide expensive treatments that have little if any support from evidence, on the other. As I started thinking about whom to turn to, Mark Mishek was the first person who came to mind. I sent him an e-mail: Could we please schedule a phone call? Once we got on the phone, I tried to explain my ideas, at that time probably not very well articulated. Mark listened patiently. Then he responded, in not too many words, but in a way that made it clear he not only understood but had been thinking about many of the same things. I explained that it was hard for me to get a real feel for the issues on the ground without experiencing the treatment environment firsthand. Could I please come to Hazelden, spend a week, talk to people, and learn? Mark put me in touch with Valerie Slaymaker, a clinical psychologist and researcher who serves as provost of Hazelden’s Graduate School of Addiction Studies. Training graduate-level addiction counselors is one of the many ways in which Hazelden has for a long time exerted a major influence on the world of addiction treatment in the United States and beyond. Valerie’s interests include addictions treatment research and the implementation of evidence-based practices into clinical programming. She seemed ideally positioned for what I had in mind.
It took nine months to find the right time, but finally we were able to schedule a visit, for which Valerie and her colleagues put together a program.
When I arrive at my destination, the first thing that strikes me is the timeless quality of the buildings, and their harmony with the countryside. As I will learn later, the original farm house by the lake, the Old Lodge, was torn down to accommodate an expansion. Only the library that once belonged to Hazel Thompson, the woman after whom Hazelden is named, was preserved, as part of a new building. The place now has more than 150 beds, and close to two thousand people come through here each year with hopes of a new beginning. Then there are the graduate school, the research center, the retreat center, and more. It is clear from the parking lots, the signs, and the maps posted on the street corners that the campus is huge. Yet at the same time it is as if the architects had tried to make the structures part of the landscape. The buildings on the gentle slopes have walls with the same color palette as the surroundings. The architecture reminds me a bit of Scandinavia, with brick walls that may not take on the elements head on but are made to resist them. Indoor walkways connect the buildings, ready to provide safe passage on a less friendly day. Half the people have names like Anderson, Carlson, or something of that nature. I try to joke with one of the women, the program director on the male Shoemaker Unit where I have my client immersion. “If it weren’t for that-and-that letter in the spelling of your last name, you could be taken for a Norwegian, too.” She smiles a wry smile. Yes, her husband’s father did change the spelling. Yes, his family was from Norway, hers from Sweden. But she’d rather talk about the unit she runs, and the people who come through it.
During the course of the week, many people open their doors for me without asking for anything in return. From those people I learn as much as I had ever hoped and more. I learn how, after somewhat shaky beginnings of the retreat for professionals with alcoholism at the Old Lodge,10 Pat Butler, a local businessman with alcoholism in the family, became the president and put the foundation on a sound financial footing. I learn how Hazelden in the 1960s, with Dan Anderson as the main architect, moved beyond a pure, traditional twelve-step approach, to make treatment multidisciplinary, over the years adding psychological and psychiatric services. From Dan Frigo, now dean of Hazelden’s graduate school, I learn about the great expansion of the Minnesota Model in the 1980s. In those days, he tells me, he worked for a company, one of many that could be hired on a consulting basis to establish treatment facilities, much like how some builders put up standard home designs wherever they go. Most of those treatment programs were purely commercial. None of them were part of Hazelden, which remains a nonprofit foundation. I learn that in 2006, more than two years before I first met Mark Mishek, Hazelden started offering anticraving medications such as naltrexone, and how, from those slow beginnings, about 40 percent of alcohol dependent patients by now leave the program with a prescription for one of these medications. That, I note, is about tenfold better than typically happens in specialized addiction medicine services elsewhere. We also talk about preparations for introducing at least limited duration of buprenorphine maintenance into treatment of opioid addiction, despite the controversy that is likely to provoke in the AA community, because that is what the data support, and because it is unbearable to see patients die in the absence of that treatment. Since my visit, that program has indeed been implemented.
I spend some time with Stacy Weaver, the supervisor for the financial case manager group, and one of her coworkers. From them I learn about the battles they frequently fight on behalf of clients with insurance companies but also about the contracts they have over time been able to negotiate with some of the major insurers.11 In the course of those conversations, we touch on other places that offer treatment, don’t take insurance, and openly cater to a clientele of means only. The Hazelden staff don’t expressly criticize those places, but they make a point of showing me how hard they try to do things differently. I learn about the partial stipends that a proportion of Hazelden’s revenue is used for to help clients offset treatment cost. I learn that a couple of beds are always available for free to county residents, as an expression of gratitude for the support of the local community. We talk about efforts to support parity laws and in other ways advance an agenda of addressing the needs of people with addictions. We talk about the need, meanwhile, to develop less costly treatment options so that more people can have access to treatment. I bring up the need I see to create a continuum of care, one that is built on a recognition that addiction is a chronic, relapsing disorder. No one objects—the issue is high on the agenda—but they point out the shortage of treatment resources when clients return to their communities. There is a fun discussion about opportunities for creating online recovery management tools that in part can help fill this gap and provide support for a long time at a low cost. I get a fascinating look at a program that is being piloted.