Against Recovery and Self-Help, Part 1
By Chris N.
My observation is that most people give credit to Alcoholics Anonymous for helping to change attitudes about the phenomenon called alcoholism. The book Alcoholics Anonymous famously claims that alcoholism is a disease, and includes “the doctor’s opinion” as part of establishing that claim.
Of course, A.A. was not first to claim that alcoholism is a disease, so this is not unique or new to A.A. or the book. One of the most bizarre things in the book is the glaring, stunning, OMLOG (O, My Lack Of God) contradiction between the claim that alcoholism is a disease rather than a moral failing, and the prescribed religious and moral treatment for that disease. But if that is bizarre, consider that legal systems send offenders, and medical treatment programs for addiction continue to send patients, to A.A. and N.A.—as though what is offered there isn’t a religion-based moral system. For no other kind of legal infraction, and for no other ailment, does our society consider it appropriate to refer people to a self-help group whose mainstream operates as an ongoing Christian moral training camp.
A.A. does have something right: that whatever “addiction” is, it is somehow different from other wrongs or ailments. It is not like committing fraud or lying to Congress; it is not like breaking your arm playing lacrosse or even a chronic condition like multiple sclerosis. But in none of those cases would we imagine that the treatment should involve sharing your “experience, strength, and hope” with others in like condition, and undertaking 12 steps aimed at a “spiritual awakening.”
There is something else that I believe A.A. has right: that for an “addict,” living without alcohol or the substance of choice takes the help of others, and the best others to provide that help are other addicts. Addiction is in some way different from acts of treason, tennis elbow, or prostate cancer. The difference of addiction that I want to discuss is also what leads me to doubt the disease model of addiction.
I will assert without argument that A.A. is wrong about the “spiritual” part of the “program.” This language originally intended to assuage worries of alcoholics concerned that A.A. was a Christian cult group, until they could be fully inculcated into the group, when its true Christian meaning could be accepted (see Schamberg on this point). A.A., at its core, is a religious program, especially in the conventional version as represented by the book of Alcoholics Anonymous. In what follows, I am simply going to reject and ignore the notion that a supernatural being would cure anyone of addiction.
The Disease Model of Addiction
Let me return to a more salient point A.A. makes: alcoholism is a disease, rather than a moral failing. Despite this, it prescribes a moral (“spiritual”) remedy. This contradiction reveals an underlying assumption in both the “moral” and disease models of addiction: it affects individuals as such. There may be conditions contributing to the development of addiction, but the addiction itself is treated as the behavioral problem of the individual. Treatments, whether moral or “medical,” are focused on the individual. The individual has the problem, the individual needs to be treated, the individual needs to be sobered up, the individual needs to have the spiritual awakening, and so on.
This assumption appears natural because it is fundamental the ideology of Liberalism and Capitalism—the fundamental and dominant set of assumptions about social reality that prevail in our society, of which a bit more anon. The assumption that it is the individual who “has the disease” and the individual who needs treatment leads to an unconscious, fast bit of reasoning. Addiction comes from continuous use of a substance. An addict must have continuously used that substance. Therefore, the addict must be responsible for the addiction. It follows that the person who needs to be treated is the addict, and the one who needs to be held to account for this addiction is the addict.
This is how the predominant models of addiction and recovery reproduce the ideology of individualism. Whatever social conditions pertain to the development of addiction, social and economic systems are usually regarded as irrelevant, and at best considered co-causal factors. Consumer capitalism is never considered as fundamental to the production of addiction and recovery; or, when it is, it is considered merely as the unchangeable, inevitable background situation, i.e., “the real world.” [1] The differences between two poor people of color growing up with discrimination in education, transportation, economic and social opportunity, one of whom becomes addicted to alcohol and one who does not, is chalked up to individual strength of character, or strong family background, or moral virtue, or religion—something outside the public sphere.
And the familiar shibboleth that “alcoholism can affect all kinds,” regardless of education or wealth or social class, allows us to ignore any of the social and economic factors that pertain to the development of addiction. It mystifies alcoholism and addiction. Underlying causation is not merely ignored, it is hidden by layers of assumption that the individual has somehow been created by itself.
This ideology leaves us with far fewer resources for understanding or ameliorating addictive and other unhealthy consumption behavior. It has us ignore the way brain chemistry works, and how a person in distress, lacking safety, security, affection, care, or a home can alleviate this distress through tricking their own brains, via alcohol or other drugs, into producing hormones that reduce the feeling of distress. We know that the repeated use of alcohol and other drugs to reduce distress is the heart of substance addiction. Therefore, we know that it is not the individual’s lack of good character, lack of moral upbringing, lack of religion that leads to addiction. We know that it is ongoing experiences of acute distress.
You don’t necessarily need to grow up a poor kid of color and consequently discriminated against in myriad other ways, to lack safety, security, affection, or care, or a home. Often the distress is not recognized, or is misrecognized as “discipline,” particularly, in my experience, among those who grew up poor or in families who did not gain much education. Furthermore, plenty of white “middle class” kids, plenty of wealthy kids, grow up in situations of tremendous ongoing distress. It is not poverty or discrimination that necessarily leads to alcoholism or addiction—no news there. It is not what we used to call deprivation. It can be as simple as neglect.
Acute distress is a complex phenomenon involving psychic, emotional pain, lack or loss of resources, lack or loss of social support or economic support, and other factors. It can, and often is, related to trauma. The rates of addiction among those who have unresolved trauma in their personal history is very high, for instance—according to the National Institutes for Health, close to half of PTSD sufferers fit the diagnostic criteria for substance use disorder, and more than one quarter fit the criteria for substance dependence disorder (the DSM-V term for addiction).[2] No one traumatizes themselves. No child neglects or abuses itself. No one dispossesses themselves economically and socially. These are harms and oppressions that a society produces, along with the so-called individual who experiences the distress of living through them.
We know that this is the heart of addiction and unhealthy consumption behavior. Yet the way we talk about addiction and recovery, leaving aside “miracles,” continues to tell us and the “individual” that the individual is responsible, the individual needs to take stock of themselves, the individual needs to do the work.
The industry of “self-help” is built on this premise. And while the idea of self-improvement is ancient, the specific concept of self-help in the modern sense belongs very much to the capitalist-individualist ideology of the first book published in this industry, Self-Help, by Samuel Smiles. Smiles’ text draws from a series of lectures he gave to audiences of laborers in the North of England, allegedly by invitation. Smiles tells us:
But to wrestle vigorously and successfully with any vicious habit, we must not merely be satisfied with contending on the low ground of worldly prudence, though that is of use, but take stand upon a higher moral elevation. Mechanical aids, such as pledges, may be of service to some, but the great thing is to set up a high standard of thinking and acting, and endeavor to strengthen and purify the principles, as well as to reform the habits.[3]
It is a story we hear often, but it simply is not true, and A.A.’s own practice shows that it is not true. What helps us is not strengthening and purifying our principles, but being able to share our woes and miseries, being able to speak in a frank way about our distress, in a space that is practically unique in the modern world. Groups of alcoholics who meet in person or online and are able to talk about their lives freely together and share their grief and their struggles, and occasionally their joys and pleasures, can provide each other support, friendship, conviviality, love, safety, connection, and community. These are all goods that our economy and society provide only scarcely and at high cost to us (especially in the cost of time).
Otherwise, for most of us, our environment continues to be the same unsupportive or oppressive situation that produces distress in the first place. For myself, being sober does not eliminate—in fact, only leaves open, raw, and more acute—the unresolved trauma of the first 20 years of my life before I began drinking, to say nothing of everyday stresses. As Gabor Maté mulled in In the Realm of Hungry Ghosts, the ecological milieu in which addiction thrives is one in which peace of mind, self-care, and general well-being are almost impossible to achieve. When “treatment” of the “individual” returns a sober person to a social milieu as stressful, oppressive, and where income divides are as inequitable as in our society, no disease has been cured, or even cared for. Maté says, “Stress is salient in the ecology of addiction… The most potent stressors are loss of control and uncertainty in important areas of life, whether personal or professional, economic or psychological.”[4] For example, at present, roughly 45% of workers in the U.S. are fearful of losing their jobs this year.[5] This is both a stressor in itself, and something out of the individual’s control.
Neoliberal, capitalist society does not provide social support or a public sphere where the question of the ecology of addiction can be addressed. To remain consistent with the ideology of this economic and social system, the individual-disease model of addiction and alcoholism must be maintained, despite its inherent contradictions. That is how the bizarre disease of alcoholism appeared in the 1930s, the only disease in modern medicine to be treated with a moral and “spiritual” program. This bizarre disease was the only one in modern medicine caused by egotism and selfishness, according to the book Alcoholics Anonymous: failings of the individual, “defects of character.” Yet even a psychiatric diagnosis of substance dependency disorder today stipulates that this is an individual’s disorder, an in that way the DSM-V continues to echo that addiction is a defect, even if it does not say “of character.”
I repeat: we know better. Alcoholism, addiction, is not a disease that an individual has. It is the predictable result we ought to expect from acute distress and lack of support, conviviality, and care. We know this, because we know that what keeps us sober is our mutual support, our conviviality, and our care.
[1] For instance, in his book Addiction, one of the oddly most economically and socially conscious books on the subject, Russell Brand makes the connection between capitalism’s dependence on unending consumption, and the addict’s own dependence. Although Brand asserts that addictive behavior is really only consumption behavior that has become overwhelmingly self-sustaining and destructive to people, he surrenders any possibility of social change to the power of capitalism.
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811127/ Accessed 23 September 2024.
[3] Smiles, Samuel, Self Help. Forgotten Books, 2012, p. 295. Originally published 1866. If you’re of the right mindset, it is as hilarious as you’d expect.
[4] Maté, Gabor. In the Realm of Hungry Ghosts. Berkeley, CA: North Atlantic Books, 2008, p. 397.
[5] https://www.usatoday.com/story/money/2024/03/07/job-market-cooling-despite-high-employment-numbers/72846912007/ Accessed 23 September 2024.
Chris N. is a sober non-believer. Critique of widely accepted ideas is his idea of a good time. He lives in central California.
For a PDF of this article, click here: Against Recovery and Self-Help, Part 1.
It is worth noting that US Government does not consider addiction a “disease” either. Despite its unquestionably disabling character, which renders earning a substantial gainful wage in the US workforce impossible, the disease is no longer regarded as a basis for a finding of disability by the Social Security Administration. This would give support to the argument of “moral failure”, as even our own government regards it as so. Otherwise, I heartily concur with all of the well-argued premises of the article. Thank you your attempt to restore some sanity to the proceedings. It is also noting that every rehab in this country, with the exception of Passages Lalibu, employs a 12-step model of addiction recovery. There is an obvious overarching financial interest at work between these rehab facilities and AA. The “recovery” community is too lazy to investigate alternative modes of alleviating the demonstrable cognitive distortions which render addiction possible.
Excellent article! Thank you.
In Part Two, if you again refer to William Schaberg (author of ”Writing The Big Book: The Creation of AA”), you might consider calling him by his actual freaken name. Otherwise, readers are left wondering, who the heck is Schamberg??
If I am misinterpreting this and there really is a Schamberg, I apologize in advance.
“The book Alcoholics Anonymous famously claims that alcoholism is a disease, and includes “the doctor’s opinion” as part of establishing that claim. What page(s) in the book makes this claim?
In the book “As Bill Sees It” to quote from the index “Disease of alcoholism; see Illness”.
In 1946 the infamous Jellinek study was published which has proven to be a real money maker for the 12 step recovery program industry:
“Jellinek coined the expression “the disease concept of alcoholism”,[8] and significantly accelerated the movement towards the medicalization of drunkenness and alcohol habituation.
Jellinek’s initial 1946 study was funded by Marty Mann[9] and R. Brinkley Smithers[10] (Falcone, 2003). It was based on a narrow, selective study of a hand-picked group of members of Alcoholics Anonymous (AA) who had returned a self-reporting questionnaire.[11] Valverde opines that a biostatistician of Jellinek’s eminence would have been only too well aware of the “unscientific status” of the “dubiously scientific data that had been collected by AA members”.[12]”
“the American Medical Association (AMA) – declared that alcoholism was an illness in 1956.[2][3] In 1991, the AMA further endorsed the dual classification of alcoholism by the International Classification of Diseases under both psychiatric and medical sections.”
I have been sober since 1980. At the time I was one of a very small minority in Canada to have attended a secular treatment program. AA was just another resource in the community for those who might be interested in it. Early on in my recovery I got to know some AA members who could be best described as free thinkers. From them I learned to think and stand up for myself. I have never thought much of the “alcoholism is a disease” concept. It just never made any sense to me.
Excellent. Thank you. “The ongoing experience of acute distress” “we know what keeps us sober is our mutual support…” Love these phrases. I think health professionals and courts continue to send people to AA because it sometimes works when nothing else does. It’s the best we’ve got. And I agree the disease concept and the no human power thing are really contradictory and simplistic.
Also, it is important to factor in the role of brain chemistry. Maybe this was what they tried to express, primitively, with the disease concept.
There’s a wagonload of false premises in this essay. AA Literature doesn’t describe alcoholism as a “disease” OR an addiction. AA is not “self-help”, either. That’s a description with no basis in AA Literature. Big Book says, at page 45, that the alcoholic’s human resources have failed utterly. Medical Science hasn’t established the CAUSE of Alcoholism, nor does AA Literature posit a cause for the illness. Most of the recent scientific inquiry on its cause has focused on Genetics, though no alcoholic gene has been identified or isolated, to date. AA groups have no opinion on addiction, alcohol reform, politics, sectarian religion, voter registration, immigration policy, or adoption of the metric system.
AA often mistakenly gets saddled with the credit (or blame) for the disease model of alcoholism. More accurately, AA member Marty Mann and the National Committee for Education on Alcoholism are due the greater share of responsibility. The NCEA message offered in the 1940s was:
1. Alcoholism is a disease.
2. The alcoholic, therefore, is a sick person.
3. The alcoholic can be helped.
4. The alcoholic is worth helping.
5. Alcoholism is our No. 4 public health problem, and our public responsibility.
There’s talk in the essay about blaming the individual. That happened WAY more when alcoholism was seen as a moral failing. Out-of-control drinking went from being viewed as ”sin” to being classified as ”an illness.” That was a step forward.
Regarding the moral treatment of a medical condition, there was a lot of that going on at the time of the birth of Alcoholics Anonymous. Christian Science and New Thought held the view that physical, mental, and especially emotional problems could be ameliorated by developing a new attitude. The Emmanuel Movement in Boston brought healing to drunkards and others who fit the label of the time — neurasthenia (anxiety, depression, anger, addiction, etc.) Even today, the medical folks recommend behaviors and habits that can alleviate these disorders.
Once God is stripped away from AA’s process, there’s some decent psychology underneath — self-examination, amends, letting go, helping others, etc. People who engage in such practices tend to get a much-needed jump in self-esteem.
Peter G. and Bob K., thanks for clarifying when the disease concept “took off” in both AA and addiction circles throughout the 2nd half of the 20th century (and still into the 21st century). The first 164 pages of the original Alcoholic Anonymous text uses the word “disease” only once and in the context of calling alcoholism a “spiritual disease” which is clearly meant as a metaphor (especially given Bill Wilson’s hesitancy to tread into medical/scientific matters).
I have been sober now for over 17 years and I have never subscribed to the disease model of alcoholism for myself. However, I have always acceded to the “dis-ease” framework for myself which as used here is also clearly a metaphor for the kind of discomfort in life that I felt and which Chris N. writes about and calls “acute distress” — which marks Chris off as someone I tend to identify with. (By the way, “acute distress” is itself a metaphor and, as such, a helpful label as long as we understand the power AND limits of metaphors.)
Although “dis-ease” sums up my sense of not feeling at home in the world (even long before I took my first drink), I would also not want to say dogmatically that all alcoholics experience their “illness” in the same way as I did or in exactly the same ways that Gabor Maté describes childhood stress and trauma as the basis of (all?) addiction.
Chronic use of alcohol over time has its physiological effects such that an addiction doctor like Dr. Ray Baker can argue that addictive substances do actually cause our brains to change their circuitry. At the recent British Columbia Secular AA Roundup this summer, Dr. Baker titled one of his Powerpoint slides as: “Yes, addiction is indeed a disease of the brain… but it’s much more.” He then proceeded to list more “non-disease” factors that make up the causes of addiction which include despair, lack/loss of positive identity, social isolation, loss of autonomy, lack of resources, etc.
This being said, however, I want to especially thank Chris N. for writing this thoughtful first part on addiction. Few writers want us to even consider the possible link between addiction and Neo-liberalism/capitalism as Chris does but, as an old fashion social democrat, I certainly have sympathies for this kind of critique. The ideology of pulling yourself up by your own bootstraps (the myth of the capitalist self-made man) is certainly antithetical to an AA fellowship that emphasizes community and connection as the very values of recovery and human wellbeing. I have often felt that it was a great irony that AA flourished so spectacularly on the very home soil of rugged individualism.
You mention a name, “Schamberg.” Did you mean the author of “Writing the Big Book,” Bill Schaberg?
Not the first time I’ve heard that one, Tommy H. Schaberg’s name gets butchered as often as not.
Well said! Thank you Chris N.
“A child who was robbed of their childhood, will burn down the village, to feel the warmth”. I am paraphrasing/butchering this quote… but you get the idea, I hope. I have always felt most of our ‘ills’ can be laid at the feet of ill-informed, neglectful parents, who were probably treated the same way as children.
I am a fan of Gabor Maté, bought ten copies of his book In the Realm of Hungry Ghosts, handed them out to friends at AA, and left several in the book cabinet for anyone to read. I experienced a double finger amputation accident at the age of six. They sewed me up, gave me pain pills, and sent me home the next day. No one considered the trauma I would experience starting school, relearning how to button buttons and tie my shoes. No one thought what it might cause me mentally. My father, the main cause of the accident, made fun of me for crying about it one day when I was 12. So I stayed silent after that, and learned to self medicate for the next 17 years. Two years of state required outpatient treatment for alcohol after a near death auto accident got me stopped, and I was sober for 25 years. But once I retired, it all came bubbling back. This story touched so many points in my life, I really can relate. AA works for those that submit to god, but they don’t have the baggage I am carrying every day. I know god abandoned me long ago. No more.
The author seems to find evidence of a conspiracy in the fact that medical knowledge advances over time. He is quite right that the DSM-5 does not consider alcoholism a disease, but rather a disorder. But at the time of the foundation of AA psychiatry was in its infancy, there was no understanding of PTSD or trauma at all beyond “shell shock” in combat. His sociopolitical observations are similarly naive, in that they assume that correlation assumes causation. Were he correct, there would be no well-to-do alcoholics, and alcohol abuse disorder clearly affects individuals across the socioeconomic spectrum. Furthermore, there is clearly a genetic component, with family members who have never interacted exhibiting similar drinking patterns. It is always tempting to believe that our addiction story is universal, but there are as many stories as there are alcoholics.
One of the best essays on the topic I have ever read. Thank you for this!