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Explanatory Frameworks for Understanding Addiction
Even if all the possible scientific questions be answered, the problems of life still have not been touched at all.-Ludwig Wittgenstein
A recent piece in The Atlantic titled, “The Irrationality of Alcoholics Anonymous,” offers a stinging indictment of the largely unquestioned status of the 12-step approach in the field of treatment. Actively and equally contributing to this monopoly are members of the legal profession (judges, mostly) and medical practitioners (physicians who in general do not know enough about addiction medicine) who sentence or recommend people go to rehab or attend Alcoholics Anonymous meetings.
The most devastating criticism raised in this article (and echoed elsewhere) is that there is no scientific evidence about the effectiveness of 12-step programs. The bite of the criticism is that a 12-step program is not based in science and therefore lacks real evidence. Thus, AA and its 12 steps really ought not to be considered a “best practice” that could justifiably be used in a treatment setting.
This is a conclusion to resist because it assumes that all questions about addiction are by nature scientific and that science can answer all the questions about addiction.-Peg O’Connor
The underpinning nexus of assumptions is that addiction is a scientific problem. Hence, only rational and scientific methods are appropriate for addressing addiction and its treatment. The title of The Atlantic article says it all: Alcoholics Anonymous is irrational. How could something irrational be the basis of effective treatment of a scientific problem? The conclusion arguably is even more far-reaching; something irrational may have no place in effective treatment. This is a conclusion to resist because it assumes that all questions about addiction are by nature scientific and that science can answer all the questions about addiction. That assumption is unwarranted.
Let me offer some significant concessions. Note that some of these are about AA with its 12 steps while others are about the uses to which other individuals and institutions put AA and the 12 steps. The 12-step approach of Alcoholics Anonymous has a staying power in part because it was one of the first somewhat systematic approaches that describes an addiction and prescribes ways of overcoming addiction in order to achieve what we now easily and habitually call sobriety or recovery. AA and many practitioners of a 12-step program have provided the primary explanatory framework for the concepts, terms and, quite crucially, the values and beliefs about addiction and recovery. It is the prevailing paradigm; it has been the framework for how the complicated set of phenomena we now recognize as addictions are understood and addressed. It is appropriate to interrogate this status especially as our understandings of addiction have become more detailed and sophisticated.
AA and many practitioners of a 12-step program have provided the primary explanatory framework for the concepts, terms and, quite crucially, the values and beliefs about addiction and recovery.-Peg O’Connor
For a host of complicated reasons that have been enumerated by others, AA and 12-step programs do not work for all. Where it does work, it often works well. It is troubling that some people including treatment professionals subscribe to the view that one’s “failure” is solely a function of her lack of effort / unwillingness / or underlying dishonesty. This is an ironic reinscription of longstanding moral judgments that may make it even more difficult for a person to address her SUD. Furthermore, it is stunning that the treatment field really has no agreed-upon standards of care, licensing, etc.
Additionally, I’ve always thought there is a tension with someone’s legal status involving mandatory attendance at AA meetings. This flies in the face of the only requirement for membership in AA being a desire to stop drinking. Even though some of the people who are sanctioned to AA later become grateful for it, that still does not justify the original sentence.
Now having made all these concessions, I want to raise a few issues and attempt to turn the conversation in a more productive way with a comparison to that science of all sciences, physics.
Usually one doesn’t think about physics in the context of addiction, but there is a valuable lesson to be learned courtesy of quantum mechanics and relativity. Usually one doesn’t think about physics in the context of addiction, but there is a valuable lesson to be learned courtesy of quantum mechanics and relativity… neither purports to be able to explain the totality of the universe.-Peg O’ConnorEach of these theories or explanatory frameworks treats reality, though they treat different dimensions or aspects. Relativity has greater success in explaining large-scale phenomena while quantum mechanics is more successful with small-scale objects. Neither relativity nor quantum mechanics is exhaustive; neither purports to be able to explain the totality of the universe. Taken together, they can tell us more about how the universe operates than each theory does separately. Each picks up where the other starts to break down. Even more interesting is that physicists don’t know if these two theories can be integrated and unified. That’s an open question that is itself the subject of great study.
So back to addiction…
Addiction is a complicated set of phenomena having biological, chemical, psychological, social, and for some, spiritual dimensions. Addiction may involve rational, irrational, or nonrational elements all at the same time. None of these dimensions is reducible to the others, which is not to claim they are entirely unrelated. Different explanatory frameworks will be much better equipped to explain certain properties of addiction and offer predictions about the best way to address them. A framework that focuses on the brain chemistry dimensions of addiction will not be the best one to focus on the social dimensions of addiction. And a framework that privileges the social dimensions of addiction may not be the best suited to address the psychological dimensions. A spiritual framework may not be the best suited to address the biology and chemistry of craving, but it may help one to wrangle with questions about value and the meaning of life that are part of many addictions.
Different frameworks address different dimensions of the reality that is addiction. One can pick up where another breaks down.
Any integration that involves the denial or rejection of particular dimensions of addiction would just create a new monopoly, which would be problematic for similar reasons as an earlier one.-Peg O’Connor
Can all these explanatory frameworks be unified? That’s an open question that requires we remain attentive to the scope or limitations of particular frameworks and the means by which they are integrated. Any integration that involves the denial or rejection of particular dimensions of addiction would just create a new monopoly, which would be problematic for similar reasons as an earlier one.
Even if all scientific questions about addiction were answered, there are still many questions left standing. These may not be subject to empirical inquiry yet they still must be lived. Science may not provide much help here, and that is totally to be expected. By no means is that an indictment of science. It certainly is not a reason to reject science. It is a reason to seek different frameworks to address these dimensions of life.
Find a framework that picks up where one breaks down.