And now, five years later? Robin has a steady girlfriend, a baby daughter and a job in social media that has enabled him to start paying off his mortgage. He and his family are about to move to San Francisco, where he will work for an internet start-up. He gave up drink and drugs slowly, cutting out one substance after another, without relying on the 12 steps for guidance. ‘They just remind me of the bad old days in rehab,’ he explains. ‘My home-made recovery was a long and messy business, with plenty of false starts, but it did work in the end.’
James is dead. He killed himself by jumping from the fifth floor of an apartment block in Johannesburg in 2006. It seems to have been a spur-of-the-moment thing, but who knows? He didn’t leave a suicide note.
How can we explain the difference in the fates of the two friends? The 12-step explanation would be that Robin was never a real alcoholic or addict, since he cured himself without following the principles of the programme. He did attend AA and NA meetings, both in and out of clinics, but found them useless. ‘AA members kept regaling me with these over-polished anecdotes about their miraculous recoveries, while the NA meetings seemed to be full of people who’d been clean for a couple of days and were obviously hoping to score.’
James, in contrast, met the sort of grisly fate that, according to the Big Book, awaits most untreated addicts. In the eyes of the fellowship, his leap from the balcony proved that he was the genuine article. One of the least attractive characteristics of 12-step ‘old-timers’ is the relish with which they describe disasters that befall those who stray from the true path.
But suppose that Robin and James had died at the same time, at the height of their drinking and drug-taking. (Robin did nearly kill himself with an accidental overdose, so it’s not an unlikely scenario.) Would a post-mortem on their brains have been able to establish which of them had the ‘progressive disease’ of addiction and which was just going through a phase? The answer is no.
Moreover, if Robin and James had been subjected to a battery of tests when they were still alive, it’s extremely unlikely that any of those tests would have distinguished between the ‘real’ alcoholic, doomed without 12-step treatment, from the ‘fake’ or temporary one, capable of curing himself. My guess is that the doctors would have said, correctly: both these young men are addicted to alcohol and drugs. But if the doctors were 12-step believers, as so many are, they might have added that neither of them could cure himself. Robin would have proved them wrong.
If you doubt that addiction medicine is heavily flavoured by 12-step dogma, let me point you in the direction of one of the most recent, supposedly authoritative, definitions of addiction by doctors specialising in the subject. It was published in 2011 by the American Society of Addiction Medicine (ASAM), which represents physicians who work with chemically dependent patients.
‘Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,’ it declares. ‘Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.
‘Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response.
‘Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.’3
This is what a definition looks like when it has been drafted by a committee. The 80 doctors who worked on it seem to have thrown everything at it but the kitchen sink. But what their definition cannot conceal – indeed, what it inadvertently reveals – is that addiction is far too complex a phenomenon for doctors to classify as a disease in the sense that cancer and tuberculosis are diseases. Hence the waffle.
Addiction specialists wouldn’t tie themselves in such knots if they had a diagnostic test for the ‘disease’ of addiction. But there is no such test.
Not only is addiction unlike cancer and diabetes, which show up in lab results. It’s also unlike brain diseases such as Alzheimer’s. That, too, lacks a simple diagnostic test: in its early stages its symptoms can be mistaken for stress or other forms of dementia. But eventually the involuntary behaviour of the patient should allow the doctor to make an accurate diagnosis, after which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.
I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.
But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.
Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.
Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?
At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.
There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.
Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4
According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction