Abstinence—The Only Way to Beat Addiction?

~ Jason Schwartz

StrawmanWhat killed Philip Seymour Hoffman? According to Anne Fletcher, it wasn’t the doctor who prescribed him the pain medication that began his relapse, it wasn’t the prescribers of the combination of meds found in his body, it wasn’t his discontinuing the behaviors that maintained his recovery for 23 years, it wasn’t a drug dealer, and it wasn’t addiction itself.

According to her it was 12 step groups for promulgating an alleged myth:

This is exactly what happened when Amy Winehouse, Heath Ledger, Corey Monteith, and most recently, Phillip Seymour Hoffman were found dead and alone. Scores of people most of us never hear about suffer a similar fate every year.

Why does this keep happening? One of the answers is that many people struggling with drug and alcohol problems have been “scared straight” into believing that abstinence is the only way out of addiction and that, once you are abstinent, a short-lived or even single incident of drinking or drugging again is a relapse. “If you use again,” you’re told, “you’ll pick up right where you left off.” Once “off the wagon,” standard practice with traditional 12-step approaches is to have you start counting abstinent days all over again, and you’re left with a sense that you’ve lost your accrued sober time.

She’s describing a theory often referred to as the “abstinence violation effect”. The argument is that the “one drink away from a drunk” message in 12 step groups is harmful and makes relapses worse than they might have been.

One problem. The theory is not supported by research. (See here and here. It hasn’t even held up with other behaviors.)

Two things are important here.

  • First, many people experience problems with drugs and alcohol without ever developing an addiction. Most of these people will stop and moderate on their own. These people are not addicts and their experience does not have anything to teach us about recovery from addiction.
  • Second, loss of control is the defining characteristic of addiction. The “one drink away from a drunk” message is a colloquial way of describing this feature of addiction.

Further, she characterizes AA as opposing moderation for problem drinkers, when AA literature itself says, “If anyone who is showing inability to control his drinking can do the right- about-face and drink like a gentleman, our hats are off to him.” 12 step groups believe that real alcoholics will be incapable of moderate drinking, but they are clear that they have no problem with people moderating, if they are able. This is a straw man.

We’re left to wonder why a best selling author and NY Times reporter would attack 12 step groups with a straw man argument and a long discredited theory.

via Abstinence—The Only Way to Beat Addiction? Part 1 | Psychology Today.

Published by Jason Schwartz

I have been an addiction professional and social worker since 1994. I started blogging in 2005 as the Clinical Director at Dawn Farm. I no longer work at Dawn Farm and am now the Director of Behavioral Medicine at a community hospital, and a lecturer at Eastern Michigan University’s School of Social Work. Views expressed here are my own. Keep in mind that the field, the contexts in which the field operates, and my views have changed over time.

6 thoughts on “Abstinence—The Only Way to Beat Addiction?”

  1. It is most odd that the most obvious determinants of relapse and death from overdose are overlooked and the recovery method that gave him quality of life for all these years is blamed. It makes you think the writer may have a hidden reason for this blindness.

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    1. Yes. It’s also hard to understand why so many of these pieces fail to distinguish between problem users and addicts. The persistence of this failure to acknowledge types of people with AOD problems makes one wonder if it’s a willful omission. And, to what end?

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  2. It seems periodically we have to relearn the lessons from the past. In the 1970s the Sobells advocated and published study results indicating alcoholics could learn to drink in a non-alcoholic fashion. Independent follow-up of the study subjects found they all suffered a relapse and some died of their disease. Dr. Benjamin Rush, a well known and respected physician of the times, in the late 18th and early 19th century advocated abstinence as the only effective way to treat alcoholism. Time has only reinforced the accuracy of both of these results.

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      1. Yes I saw that this morning.

        Two things are striking to me.

        First, how influential the Sobell study has been when it had only 20 controlled drinking subjects with only one subject having a good long term success with controlled drinking. To me, its influence says a lot about how much we value drinking.

        Second, identifying abstinence as the goal that produces the best outcome is somehow conflated with coercion. This sets up straw man arguments against abstinence. One can believe abstinence is the best treatment goal and be non-coercive. Is my doctor coercive when he suggests diet and exercise is essential to good cardiac health?

        It also illuminates the need to develop better typologies for substance use problems. Using dependence as a proxy for addiction generates too many false positives for addiction. I fear the DSM-5’s continuum model will only make matters worse.

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