How should we treat addiction?

The leader of the largest alternative to AA sounds off on why 12 steps shouldn't be the only model for sobriety

Published September 3, 2012 1:30PM (EDT)

This article originally appeared on The Fix.

To some, it might come as a surprise that Bill Wilson's innovation, the 12 Steps, aren't the only organized path to recovery. In fact, there are a handful of alternatives, the most reputable of which are listed in the Fix 411, some of which require abstinence from drugs and alcohol, and others that preach a more moderate approach, often referred by the umbrella term of "harm reduction." There is LifeRing, Moderation Management and Rational Recovery. To many members of the "Anonymous" groups—that's AA and NA, et al—these alternative programs are inferior products, ineffective and saddled by controversy. Moderation Management, for instance, has been criticized because, among other things, its founder, Audrey Kishline, renounced the program publicly in 2000 and relapsed, killing two people in a drunk driving accident. Bill Clegg, the memoirist who wrote Portrait of the Addict as a Young Man and 90 Days, said in an April interview with The Fix that harm reduction is "the first stop for people on the way down." When it fails, he says, "you are driven into a more serious program and probably just keep on going down the stairs until you get to the basement with the rest of us."

the fix Maybe so, although psychologist Tom Horvath, the owner and operator of Practical Recovery, in San Diego, has a very different view. The two Practical Recovery rehabs he runs instead espouse something called Smart Recovery, an organization he calls "the leading non-12-Step, self-empowering support group," with around 700 meetings worldwide. Smart Recovery doesn't require abstaining from chemicals, nor does it embrace the concept of powerlessness central to working the 12 Steps. So what does he believe? It all starts with taking your will and your life back.

What is the main difference between most rehabs, which generally use the 12 Steps, and Practical Recovery?

The fundamental split is between self-empowerment and the powerlessness approach—from a technical perspective these both hinge on the psychological variable called “locus of control.” Think about your expectations of the future. If you have an internal locus of control, you expect that the future is going to be what you make it. If you have an external locus of control, you expect the future is about what happens to you.


In reality, life is both of these things. The serenity prayer actually captures it very well. AA is a serenity, powerlessness and acceptance kind of program. The self-empowering approaches are based on courage, activity and empowerment. These mean that if you have cravings, rather than going to meetings I am going to learn how to deal with cravings. If I have problems, I am actually going to solve them and do the best I can with them. In a Practical Recovery facility, we work on identifying the problems people have, which always include craving and always include motivation; then, whatever their personal problems are, changing their situations, improving their relationships and achieving lifestyle balance.

We also work on identifying a deeper sense of purpose and meaning, and getting on with life. Sometimes it does not happen very quickly. I am not claiming that we are better than anybody else in terms of ultimate outcomes. Maybe we are and maybe we are not. I have no data to claim that we are better. I do think we are better for some people, in that they can work with this approach better than they can work with the powerlessness approach.

In New York City and Los Angeles you couldn’t swing a cat without hitting an AA meeting. Why aren't there more Smart Recovery meetings?

Maybe we just haven’t been around long enough. I think that if people had an equal opportunity to choose between a 12-step meeting or Smart Recovery—just based on a couple of situations I’m aware of—I think they would split around 50/50. If we had more groups—let's say when we have more groups—then we will be a very important option for half the population that will go to a support group. Of course, many people will not go to a support group.

To say to somebody, “AA is the only thing that works,” is the height of unethical behavior in our field. It is unethical because it is not factual. There are many roads to recovery. Most people who recover do not get any kind of services. They do not go to support groups or any kind of treatment. They do it via that mysterious process we call “natural recovery.”

Is addiction a disease?

That is one of the big questions, isn’t it? Practical Recovery has recently taken the same position on this that Smart Recovery takes, which is that we will work with you regardless of what you think. The answer doesn’t really matter to us.

Right. It really doesn't matter what we call it.

Our treatment plan is not going to change either way. If it is a disease, how do people actually recover? It includes things like exercise, lifestyle balance, healthy eating, getting proper sleep, and identifying and resolving your underlying problems. Getting social support and improving your relationships. There is a lot in recovery that is pretty consistent for people who are successful.

That sounds a lot like the 12-Step process.

That certainly could be a 12-Step process. The crucial difference is that powerlessness aspect. If people call me and they have never been to a 12-Step group, I tell them they should go. If you can work with that approach, it is easily available. There is a lot of support for doing it. However, there are a lot of people who just will not do it. They just will not go to AA. Rather than telling them that they have to, we are presenting an alternative. There are about ten rehabs around the country now that do Practical Recovery. Plus there are these five alternative support groups, Smart Recovery being the most prominent. I believe that over time, it may take two or three decades, the self-empowerment approach will become about 50% of the marketplace, which is roughly what it is in the rest of the world. The United States is anomalous in terms of the dominance of AA.

So, can alcoholics learn to moderate their drinking?

Absolutely. Some of them. The Federal Government data is very clear on this. If you Google the phrase “Alcoholism is not what it used to be,” you will come up with a summary of the National Epidemiological Survey on Alcohol Related Conditions (NESARC). It finds that around half of the people who have had a diagnosis of alcohol dependence end up moderating successfully. That is a pretty high number.

Is that one of the goals of Practical Recovery, to teach moderation?

No. Our goal is to help people make sensible decisions and act on them effectively. We take no position on moderation or abstinence, regardless of the seriousness of your problems. We help you make a decision and implement it. We are not an advocate of either one.

What about other substances? Can crack smokers moderate crack smoking?

That is an interesting question. Probably some of them can. They have not come much to the attention of scientists. We know, and the Centers for Disease Control and Prevention knows, that some heavy smokers are able to moderate their smoking. When I read that years ago, I realized that, at least in theory, this was possible for anybody. The crucial distinction is that most of the people who get the treatment are already at the pretty severe end of the spectrum. As a default position for other substances, my default position is abstinence. What other people choose to do after treatment is up to them.

Twenty million Americans are diagnosable with some range of chemical dependency. What is it about the addiction treatment field that we are missing?

Well, the treatment system is not attractive enough for most of those folks. A system that is more harm-reduction oriented, which is what you have in most countries, would pull more people in and hopefully help them make resolution faster. The other piece is that recovery is not ultimately about treatment. It is about something much bigger than treatment. It is about society. The American society is one that breeds addiction rather well. Until some of those changes occur, and keep in mind that I am not expecting that, we'll always have substantial addiction problems.

In Practical Recovery or Smart Recovery, how is success defined?

We let people define that for themselves, generally speaking.

So relapse is not viewed as failure?

Absolutely not. In fact, that is one the biggest benefits of a Smart Recovery meeting. If we are talking about Smart now, people come back and they talk about their slips and their relapses. Those are some of the most powerful meetings. We do not honor sober time the same way that 12-step groups do with tokens and chips and so forth. Everybody is sad that you just had three months and you relapsed, but let's hear about what happened so that we can all learn from it.

I’ve always thought the way we diagnose addictive behavior isn’t diversified enough. A heroin addict and a wine-sipping housewife are put in the same form of treatment.

The treatment should be very different.

What do you say to the AA evangelicals who say that there is no other solution?

That is just ridiculous. There is so much scientific evidence that shows there is a wide range of solutions. AA is associated with recovery, but no one has ever demonstrated a cause-and-effect relationship. That often gets left out of the discussion. I am willing to believe that with the proper studies done, we would find that AA causes recovery for some people. I just assume that.

Does AA work?

We really don’t know. I am willing to believe it works. The point is there are half a dozen other things that are rather different than AA, that also work probably about as well. To say to somebody, “AA is the only thing that works,” is the height of unethical behavior in our field. Unfortunately, it is common. It is unethical because it is not factual. There are many roads to recovery. Most people who recover do not get any kind of services. They do not go to support groups or any kind of treatment. They somehow do it via that mysterious process we call “natural recovery.”

That is probably true.

It is absolutely true. There is data, very solid data, that supports it. How many people quit cigarettes by going to rehab? Not many. Most people quit drinking on their own. Most people quit heroin on their own. Treatment is a small part of what actually happens.

Is it dangerous to tell people that they can quit on their own? Isn’t that emphasis on self-reliance—"Oh, this time I really mean it"—one of the things that gets people further into their addiction?

We should be telling people that the fundamental element in change is the decision to change, and that decision, when backed up by sensible action, is what creates recovery. Sensible action may include getting treatment. In many cases it does not. That is the foundation of recovery, not going off to rehab. Rehab has its place—I own and operate two of them, and I’m very proud of them—but I have never told anyone they had to come to our rehab, or any rehab, or they were not going to make it. The facts do not fit that.

Right. So the whole culture of AA, is it the Tea Party of recovery? They are opposed to science. They do not like medication. They are rooted in something that nobody really knows if it works or does not work.

Well, AA is a big organization. It has a lot of different kinds of people in it. My only request is that when people show up at an AA meeting, that they get told this is one way to recover. We sure hope it works for you. You are welcomed back. We have got a lot to offer you. If you do not think this is right place for you, let me tell you about some others. Here is a list of other things you can do.

That is never going to happen.

Not any time soon.

We hear a lot about the idea of moderating drinking and Moderation Management with Smart Recovery. MM started with Audrey Kishline in 1994. She claimed she could moderate her drinking with therapy and other things, and ended up in 2000 killing two people in a drunk driving accident.

Let's talk about Audrey Kishline. Do you know the group she was a member of when that happened?

Moderation Management.

Absolutely not.

She was in AA?

She was an AA member for the previous two months. This is easily documented. I have been in the field for 27 years and there is a group of us around the country that stay in close connection. I knew Audrey. She posted a whole bunch of places on the Internet in January of that year. The crash was March. She said, "I have decided that moderation is not the best approach for me. It is not working currently. I am joining AA. I wish MM the best. I will no longer be affiliated with it." Two months later is the collision. That is not AA's fault. It is sure as hell not MM's fault.

Right. The popular thing is like when you say to people, and I am curious to know how you would respond, when you say to people "Oh, well maybe Moderation Management." No, that woman killed a family. That is sort of the response that people give. I think that is the messaging.

I am doing everything I can to change that. A blood-alcohol content of 0.27 or 0.23, whatever she had, is nobody's definition of moderation.

No. Clearly not. And obviously we have no idea who many members of AA have killed anyone in drunk driving accidents.

Quite a few, I am sure. It is a wide reaching organization.

Do you think that the anonymity is something that can be used to shield against accountability?

For sure. Of course, I am not proposing that people start mentioning their last names at AA meetings. One of the problems, I think, is that because no one speaks for AA, the irony is that then everybody speaks for AA. There is nobody to contradict them. If somebody could stand up in a meeting and say "You know, AA's policy is that we support other options in recovery and you need to sit down and shut up. You are saying something different and that is not AA policy." That would go a long way toward changing the field.

I agree. Addictive illness is something that impacts every single American. I do not disagree with anything you are saying. I do not disagree with any approach. I do not think there is any right or wrong way to be sober or get sober.

I have drafted up a mission, purpose, vision and values statement for an organization that I am tentatively calling the Association for Addiction and Recovery. I can see it as this umbrella organization like the American Heart Association or something. It is kind a non-denominational place where everybody could come together and support common sense improvements. The field is pretty divided, though. I do not know if it would work. Right now, I see more fighting that unification. I think the The Fix is part of the solution. I am very impressed with what you guys are doing.

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