10/29/19

Do They Walk Their Talk?

Matthew 7:15 cautions us to “Beware of false prophets.” By their external appearance, they look authentic and may even do or say some of the right things. Like wolves in sheep’s clothing, they appear to be the real deal on a superficial level, but inwardly they are vicious and destructive. So how can you tell a true prophet from a false one? The answer is, do they bear good fruit—do they walk their talk?

The concluding section of the Sermon on the Mount makes use of the “Two Ways” tradition of early Christianity and Judaism. In three illustrations, Jesus plainly showed there are only two categories of people in the world—those who enter by the narrow gate rather than the wide gate (vv. 13-14), those who bear good fruit rather than bad (vv. 15-20), and those who build their homes on solid rock rather than shifting sand (vv. 24-27). In his commentary Leon Morris commented, “In each case the first category refers to those who hear, obey, and are saved; the second, to those who only hear and so are destroyed.” In other words, not everyone who says they are a Christian, is a Christian. They have to show it.

¹⁵“Beware of false prophets, who come to you in sheep’s clothing but inwardly are ravenous wolves. ¹⁶You will recognize them by their fruits. Are grapes gathered from thornbushes, or figs from thistles? ¹⁷So, every healthy tree bears good fruit, but the diseased tree bears bad fruit. ¹⁸A healthy tree cannot bear bad fruit, nor can a diseased tree bear good fruit. ¹⁹Every tree that does not bear good fruit is cut down and thrown into the fire. ²⁰Thus you will recognize them by their fruits. (Matthew 7:15-20)

The contrast of the two ways is not found in the other gospels, but it does appear in the Old Testament (Deuteronomy 30:19; Psalm 1:6, Jeremiah 21:8); in Jewish writings (2 Esdras 7:6-13); and in early Christian literature, like Didache 1:1: “There are two ways, one of life and one of death, and there is a great difference between the two ways.” Some may verbally affirm that Jesus is Lord, and even preach the gospel, but inwardly are insatiably after their own interests. They are like ravenous wolves. So how can you tell who is a wolf in sheep’s clothing? By their fruits: “Their fruits will in the end betray them.”

Jesus used an illustration from the everyday life of his audience to demonstrate this. Everyone knew that the buckthorn had small black berries that could be mistaken for grapes. And there was a thistle whose flower could be mistaken for a fig, from a distance. However, as D.A. Carson said, “But no one would confuse the buckthorn and the grape once he started to use the fruit to make some wine. No one would be taken in by thistle flowers when it came to eating figs for supper.” The same principle is true of trees—a good tree bears good fruit; a diseased tree bears bad fruit.

Here the thought is that it is not the outward appearance that is important (wolves may be dressed up to look like sheep), but the things the false prophets do, the produce of their manner of thought and life. If the disciples take note of what these false prophets do and refuse to be charmed by their false words, they will recognize them for what they are.

If a tree is healthy, it cannot bear bad fruit. Conversely, a diseased tree cannot bear good fruit. The repetition emphasizes the point. Then Jesus moved to the fate of every diseased trees: “No bad tree is allowed to continue producing its bad fruit.” The consequence is universal; it is cut down and burned.

The burning of a worthless tree removes the possibility that it will infect other trees. But fire is often used of the fire of hell, and this meaning may be not far away. Jesus is making it clear that discipleship means a great deal more than religious activity.

So then, the logical conclusion of Jesus’ teaching here is a repetition of verse 16. “You will recognize them by their fruits.” The good fruit of a person’s life is the evidence of their claim to be a prophet. And since good fruit cannot grow on a diseased tree, you can discern a false prophet by their fruit as well. False prophets, like diseased trees, should be cut down and thrown into the fire.

The Old and New Testaments contain multiple warnings against false prophets. They commit adultery, walk in lies and strengthen the hands of evil doers (Jeremiah 23:14); they are treacherous and do violence to the law (Zephaniah 3:4); they prophesy lies in the name of God, the deceit of their own minds (Jeremiah 14:14). The Bible suggests these false declarations come from their own hearts (Ezekiel 13:2, 4; Jeremiah 23:16, 26). We can suggest that at least one of the ways to uncover a false prophet is to watch and see if they demonstrate their love for God by walking their talk. But what if the false prophet is a wolf in sheep’s clothing—what if they appear good on the outside?

There is a root and fruit connection to our actions (fruit) and our heart (root). A “healthy tree bears good fruit, but the diseased tree bears bad fruit.” The parallel to our Matthew passage in Luke 6:43-45 declared the good person produces good treasure from his heart and the evil person produces evil treasure from his heart, “for out of the abundance of the heart his mouth speaks.” In Instruments in the Redeemer’s Hands, Paul Tripp illustrated this process in his discussion of fruit stapling, where efforts to change behavior ignore the heart behind the actions.

Drawing on the fruit tree metaphor in the Luke passage, he asks us to imagine that he has an apple tree in his backyard. Year after year the apples are dry, wrinkled, brown and pulpy. His wife says it doesn’t make any sense to have an apple tree that doesn’t produce good fruit and suggests that Paul cut down the tree and burn it. Instead, he buys branch cutters, an industrial grade staple gun, a ladder and two bushels of apples. He climbs the ladder, cuts off all the pulpy apples, and staples shiny red apples on every branch of the tree. “From a distance our tree looks like it is full of a beautiful harvest.”

If a tree produces bad apples year after year, there is something drastically wrong with its system, down to its very roots. I won’t solve the problem by stapling new apples on the branches. They also will rot because they are not attached to a life-giving root system. And next spring, I will have the same problem again. I will not see a new crop of healthy apples because my solution had not gone to the heart of the problem. If the tree’s roots remain unchanged, it will never produce good apples.If my heart is the source of my sin problem, then lasting change must always travel through the pathway of my heart. It is not enough to alter my behavior or to change my circumstances. Christ transforms people by radically changing their hearts. If the heart doesn’t change, the person’s words and behavior may change temporarily because of an external pressure or incentive. But when the pressure or incentive is removed, the changes will disappear.

Sooner or later they will show the wolf; a diseased tree always bears bad fruit. They cannot consistently walk the talk because the seemingly “good fruit” does not come from a changed heart.

The root-and-fruit principle applies readily to 12 Step recovery. Several of the sayings used in recovery, such as walking your talk, he’s on a dry drunk, you can’t be clean while living dirty, are illustrations of it. It even applies to judging your spiritual experiences and whether or not you can ever ‘get’ clean.

Bill W. wrote an article originally published in the Grapevine in July of 1962, “Spiritual Experiences.” It was later added to a collection of his Grapevine writings, The Language of the Heart. He said he was the recipient of a tremendous mystic experience in 1934 that was “accompanied by a sense of intense white light, by a sudden gift of faith in the goodness of God, and by a profound conviction of his presence.” He said in retrospect, the only special feature was its electric suddenness and the overwhelming and immediate conviction that it carried to him. “In all other respects, however, I am sure that my own experience was not in the least different from that received by every AA member who has strenuously practiced our recovery program.”

He said when a person approached him to find out how to have a sudden spiritual experience, he tells them that in all probability they have had one just as good, except it was strung out over a longer period of time. If a spiritual transformation over six months had been condensed into six minutes, “well they then might have seen the stars, too!” He failed to see any great difference between the sudden and more gradual experiences; they were certainly all of the same piece. The one sure test of any spiritual experience was, “By their fruits, ye shall know them.”

As Bill Sees It is a collection of selected writings by Bill W. In there was an excerpt from a 1958 letter Bill wrote to a person discouraged over repeated “slips,” lapses back into active drinking. The discouraged individual was thinking of not returning to A.A. because of his lapses. Bill advised him against staying away from A.A. because of feeling of discouraged or shameful of his lapses. “It’s just the place you should be.”

For some reason, Bill said, the Lord seemed to have him on a tougher path. But God was not asking for him to be successfully abstinent, “He is only asking us to try to be.” Here was the key feature in achieving lasting abstinence—a transformed heart; a surrender of your will and life to God after recognizing your powerlessness to do so in your own strength. And whether this spiritual experience was sudden or gradual, the sure test of whether it was real was by its fruit. If there was a true surrender, he would get the program. “It is not always the quantity of good things that you do, it is also the quality that counts.”

This is part of a series of reflections dedicated to the memory of Audrey Conn, whose questions reminded me of my intention to look at the various ways the Sermon on the Mount applies to Alcoholics Anonymous and recovery. If you’re interested in more, look under the category link “Sermon on the Mount.”

04/2/19

The Narrow Gate

Bill W., the cofounder of Alcoholic Anonymous, heralded the compromise of ‘God as we understood Him’ as “The great contribution of our atheists and agnostics. They had widened our gateway so that all who suffer might pass through, regardless of their belief or lack of belief.” Yet he also personally met weekly with Monsignor Fulton Sheen for the better part of a year and took his instruction seriously. Ultimately he did not convert to Catholicism, irked by how all organized religions “claim how confoundedly right all of them are.”

Every time this dubious principle of religious rightness takes a firm grip on men’s minds, there is hell to pay, literally. In a sense, it’s worse than nationalistic rightness or economic rightness, those scourges of the moment. The ungodly might not be expected to know any better. But men of religion should. Yet history shows that they just don’t. It seems to me that the great religions survive because of their spirituality and in spite of their infallibility.

He was also hesitant to convert because he was seen as a symbol of A.A. “And A.A. as a whole does not make any endorsements or commitments. There is the rub.” He lamented churches didn’t have a fellow-traveler department: “Oh, if the church only had a fellow-traveler department, a cozy spot where one could warm his hands at the fire and bite off only as much as he could swallow. Maybe I’m just one more shopper looking for a bargain on that virtue—obedience!”

Ultimately, it seems Bill hesitated because Christianity requires a complete commitment to Christ; there is no fellow-traveler department: “I am the way, and the truth, and the life. No one come to the Father except through me” (John 14:6). In New Wine: The Spiritual Roots of the Twelve Step Miracle, Mel B. said that Bill took the broad view that there were many paths to spiritual experience and growth; and he did not think adherence to Christian religion was a prerequisite. In a personal communication to Mel, Bill said while Christ was the leading figure to him:

Yet I have never been able to receive complete assurance that He was one hundred percent God. I seem to be just as comfortable with the figure of ninety-nine percent. I know that from a conservative Christian point of view, this is a terrific heresy.

This cozy spot by the fire, where someone could warm his hands and only take as much as he could swallow, is known as nominal discipleship—something not possible for a follower of Christ. In Matthew 7:13-14, Jesus said: “Enter by the narrow gate. For the gate is wide and the way is easy that leads to destruction, and those who enter by it are many. For the gate is narrow and the way is hard that leads to life, and those who find it are few.” Note the formal structure of the verses, beginning with the command to enter by the narrow gate:

Enter by the narrow gate.

For the gate is wide and the way is easy

that leads to destruction,

and those who enter by it are many.

For the gate is narrow and the way is hard

that leads to life,

and those who find it are few.

This passage begins the concluding section of the Sermon on the Mount, where Jesus clearly says there are only two ways of life. The three illustrations that follow contrast those who select the narrow rather than the wide gate (13-14), those who bear good fruit rather than bad (15-23) and those who build their homes on solid rock rather than sinking sand (24-27). The contrast of this “two-ways” genre is found in other Jewish literature (2 Esdras 7:1-16), the Old Testament (Deuteronomy 30:19; Jeremiah 21:8), and early Christian literature (Didache 1:1; Epistle of Barnabas 18:1). Craig Blomberg in his commentary on Matthew said: “By these three illustrations, Jesus makes plain that there are ultimately only two categories of people in the world, despite the endless gradations we might otherwise perceive.” In his commentary on Matthew, John Nolland said:

Matthew has probably chosen the imagery of narrowness to suggest the constriction of one’s choices involved in taking the challenge of Jesus’ teaching: there is a very sharply defined mode of entry. The narrow gate throws up images of the need to make a choice which is not obvious (this is not where the crowd is going to go), to be attentive to where the gate is located, perhaps to experience the discomfort of squeezing through a narrow space, and possibly to wait patiently while others are going through the gate.The alternative to the narrow gate is a wide gate: the unstated assumptions are that everyone must go through a gate and end up somewhere and that only two gates exist. The default choice is clearly seen to be the wide gate: a wide gate beckons in a way that a narrow gate does not; a wide gate suggests an important destination; a wide gate (such as the main gate of a city) is set up to deal with the movement of large numbers of people.

But Bill W. and A.A. were not trying to promote a broader, easier way to Christ. They sought to “widened our gateway so that all who suffer might pass through, regardless of their belief or lack of belief.” They sought to follow the distinction made by William James in The Varieties of Religious Experience between personal and institutional religion. He defined personal religion/spirituality for his purposes as “the feelings, acts, and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine.” In the broadest sense possible, this religion or spirituality consisted of the belief that there was an unseen order to existence and supreme good lay in harmoniously adjusting to that order.

Worship, sacrifice, ritual, theology, ceremony, and ecclesiastical organization were the essentials of institutional religion. Limited to such a view, religion could be viewed as an external art of winning the favor of the gods. Within the personal dimension of religion, the inner dispositions of human conscience, helplessness, and incompleteness were of central importance. Here the external structures for winning divine favor took a secondary place to a heart-to-heart encounter between the individual and his or her maker.

Bill’s view of religion fits within this Jamesean distinction between personal and institutional religion—a distinction we see today as spiritual and religious. The widened gateway for the Twelve Steps of ‘God as we understood Him’ is consistent with the wide gate Jesus described in Matthew 7:13. It is not the way to life. However, it does provide a way to abstinence—a way out from the powerlessness of alcohol and drugs. It will crisscross the narrow way at many points, but needs to be seen as a distinct path. See “A Common Spiritual Path” and the other reflections under the category link “Romans Road to Recovery” for more on this issue.

There is a way and a gate that leads to life and a way and a gate that leads to destruction. The wide gate and way is easy, leading to destruction, while the narrow way and gate is hard, leading to life. Many find the wide gate, but few find the narrow one.

02/5/19

Another Bozo on the Bus

“For there is no distinction: for all have sinned and fall short of the glory of God” (Romans 3:22-23a). The main thing alcoholics have in common is they all drink to get drunk. Just as there is nothing to serve as a possible ground for someone being a ‘lesser’ or ‘worse’ sinner before God, in Twelve Step recovery there are no differences among alcoholics or addicts, since all are powerless over alcohol. In “Just Another Bozo on the Bus,” an anonymous AA said in his Grapevine article that the story of his sobriety was one of a growing realization of all the ways he was exactly like others in Alcoholics Anonymous. “That experience of being ‘the same as,’ of being ‘one among many,’ of being ‘just another bozo on the bus’ is critical to the maintenance of my spiritual condition.”

This sense of ‘no distinction’ lies at the heart of Twelve Step recovery: “We are either all alcoholics with no distinction (and therein lies our power) or we might as well shut up shop.” It is truly is a matter of life and death: “There are no distinctions made for color, race, economic status, or education. We are all equal and have to reach out to one another in order to survive.” Felicia G. recalled how two women first talked to her about what she would find in AA: “It is a pattern and you are not alone. You are not the only woman who has been like this. Thousands and thousands of men and women have been like this. And now they are sober.” An anonymous twenty-year old AA put it this way:

To me, God is an artist and he sculpts people into what they really are. He accomplishes this through the Twelve Steps. I can see he has done this, and is still doing this, with my friends and me. Although we are all sculpted differently, there is a certain fact that holds us all together. That fact is alcoholism. I have heard it referred to as the “great equalizer.” Now AA is the great equalizer in my life because no matter what people have done, thought, or felt, if they are alcoholics, we have a common bond.

The self-same sense of oneness exists within Narcotics Anonymous (NA). Like “a lifeboat in a sea of isolation,” NA is: “a fellowship of people with a common bond of recovery.” They all have one thing in common: “All of us, from the junkie snatching purses to the sweet old lady hitting two or three doctors for legal prescriptions, have one thing in common: we seek our destruction a bag at a time, a few pills at a time, or a bottle at a time until we die.” The common problem was addiction and no one was greater (or less) than any one else: “No member is greater or lesser than any other member.” Herein lies its power: “We found that no matter what our past thoughts or actions were, others had felt and done the same. Surrounded by fellow addicts, we realized that we were not alone anymore.”

This common bond—whether it is sin or addiction/alcoholism—this great equalizer cuts across all peoples. We do not understand our actions. We do the very thing we hate. We have the desire to do what is right, but not the ability to carry it out. “For I do not do the good I want, but the evil I do not want is what I keep on doing” (Romans 7:15-20). We are powerless; we are sinful.

There are no social or cultural distinctions made by God with regards to the universal sinfulness of all people; regardless of their particular sin, they all fall short. “There will be tribulation and distress for every human being who does evil, the Jew first and also the Greek” (Romans 2:9). Here, and other places in Scripture ‘Greek’ can be an equivalent for those who are non-Jews or ‘Gentiles.’ Everyone who sins, Jew or non-Jew (Greek or Gentile), faces tribulation and distress.

In the Sermon on the Mount, Jesus addressed the human tendency to deny or minimize personal sinfulness when He said that whoever relaxed one of the least of the commandments and taught others to do so, would be least in the kingdom of heaven (Matt. 5:19). Anger has the same liability for judgment before God as murder; a man who looks lustfully at a woman has already committed adultery in his heart (Matthew 5:21-30). Paul clearly had this sense in mind when he said that the “dividing wall of hostility” has been broken down in Christ (Ephesians 2:14). But we need some context to fully understand the significance of Paul’s statement here.

Paul traveled to Jerusalem and was counseled by James and others to demonstrate his obedience to Jewish religious law by purifying himself in the temple. Jews from the province of Asia had spread the rumor that Paul taught Jews living among the Gentiles to forsake Moses by not circumcising their children; to stop keeping Jewish religious customs (Acts 21:21). The Christian leaders wanted Paul to demonstrate this was not true; that he even continued to follow Jewish religious law himself. Some Ephesian Jews saw Paul in the temple as he completed this rite of purification and assumed he had dared to bring an Ephesian Gentile named Trophimus into the temple with him. They raised an alarm, seized Paul and beat him (Acts 21:27–32).

The inner court area of the temple in Jerusalem was raised slightly above the outer court of the Gentiles and surrounded by a barrier. Notices in Greek and Latin warned that no responsibility would be taken for the probable death of any Gentile who ventured within. According to The IVP Background Commentary: New Testament, taking a Gentile beyond the dividing wall of the outer court in the temple was considered to be such a serious breach of Jewish law that the Romans permitted Jewish leaders to execute those who violated this law. The Ephesian Jews accused Paul of violating this law.

Paul was imprisoned and later transferred to Caesarea when a plot to assassinate him was discovered. He remained in prison there for two years. Eventually he appeared before the newly appointed governor, Festus. Another plot to ambush and kill Paul during his transport back to Jerusalem to stand trial before Festus was thwarted by Paul’s appeal to Caesar.

Paul said he had done nothing wrong against the law of the Jews, the temple, or against Caesar. He was willing to die if found guilty of anything deserving death but rejected Festus’s request to return to Jerusalem for trial. Since the charges against him were not true (the Jews could not prove any of their charges), Paul said no one had the right to hand him over to the Jews, so he appealed his case to Caesar (Acts 23:20-33; 25:1-12). Paul was transferred to Rome, where he wrote the epistle to the Ephesians from prison. This set of circumstances has a somewhat poetic circle to it: the riot in Ephesus; the Ephesian Jews accusing him in Jerusalem; Paul’s appeal to Caesar; and then his writing the epistle to the Ephesians from Rome.

The believers in Ephesus would have been aware of the circumstances of Paul’s arrest and imprisonment. So his statement in Ephesians 2:14 about Christ breaking down the dividing wall between Jews and Gentiles had a special meaning to them, since a dispute over Paul violating the dividing wall in the temple was what had precipitated his arrest. Originally separated from Christ and strangers to the covenant of promise, Gentile believers have been brought near by the blood of Christ. Breaking down the dividing wall of hostility in his flesh, Christ has created in himself one new man, reconciling both Jew and Gentile in one body through the cross (Ephesians 2:11-16). So the divisions between Jew and Gentile, the circumcision and uncircumcision are no longer valid in the body of Christ. The dividing wall of hostility has been destroyed.

If somewhere within human diversity, there is a people group whose sinfulness is less than (or more than) others, there cannot be a universal need for salvation in Christ. Charles Hodge said that the universal nature of sin is “one of the most undeniable doctrines of Scripture, and one of the most certain facts of experience.” Until this fact is admitted, there is no place or need for the Gospel. Everyone who calls upon the name of the Lord, whether they are Jews or Greeks (non-Jews), will be saved (Romans 10:12-13). “There is neither Jew nor Greek, there is neither slave nor free, there is no male and female, for you are all one in Christ Jesus” (Galatians 3:28). “Here there is not Greek and Jew, circumcised and uncircumcised, barbarian, Scythian, slave free; but Christ is all, and in all” (Colossians 3:11). “For God shows no partiality” (Romans 2:11). And I am just another bozo on the bus.

If you’re interested, more articles from this series can be found under the link for “The Romans Road of Recovery.” “A Common Spiritual Path” (01) and “The Romans Road of Recovery” (02) will introduce this series of articles. If you began by reading one that came from the middle or the end of the series, try reading them before reading others. Follow the numerical listing of the articles (i.e., 01, 02, etc.), if you want to read them in the order they were originally intended. This article is the 8th in the series. Enjoy.

01/15/19

Born of the Flesh

Bill W. had just finished telling his companion about how he was finished with liquor forever. “I’m one of those people who can’t manage it.” Among other things, he described the allergy and the obsession when he drank. Then the bartender brought them each of them a drink, saying it was on the house because it was Armistice Day. Without a moment’s hesitation Bill drank it down. His friend said: “My God, is it possible that you could take a drink after what you just told me? You must be crazy.”

The Psalmist declares that we were diseased and depraved from the beginning: “Behold, I was brought forth in iniquity, and in sin did my mother conceive me” (Psalms 51:5). A favorite term of Paul’s when describing this depravity is flesh: “I am of the flesh, sold under sin” (Romans 7:14); “For I know that nothing good dwells in me, that is, in my flesh” (Romans 7:18); “with my flesh I serve the law of sin” (Romans. 7:25); “the mind that is set on the flesh is hostile to God” (Romans 8:7); “make no provision for the flesh, to gratify its desires” (Romans 13:14). In this sense, sin is the great leveler. “All have sinned and fallen short of the glory of God” (Romans 3:23).

So when he listed the works and desires of the flesh in Galatians 5, Paul was complementing the list of “lusts of the heart” and “all manner of unrighteousness” described in Romans 1. Our flesh is ruled by lust and unrighteousness; it is depraved. “Sin never consists in a voluntary act of transgression.” It is something more deeply rooted than mere free will. In the New Bible Dictionary, John Murray said:

From whatever angle man is viewed, there is the absence of that which is well-pleasing to God. . . . all have turned aside from God’s way and become corrupted. . . . there is no area or aspect of human life which is absolved from the sombre effects of man’s fallenness, and hence no area which might serve as a possible ground for man’s justification of himself in the face of God and his law.

This sense of ‘flesh’ means something in addition to our mere physical body. Turning to Galatians 5:16f, we see that Paul contrasts flesh and Spirit, saying that the desires of the flesh are opposed to the desires of the Spirit; and that this opposition is so that we can’t do the things we want to do. God intends for us to be powerless over the desires of the flesh, over this deeper sense of sin so that we will in turn realize our need for Christ: Romans 7:24-25 says: “Who will deliver me from this body of death? Thanks be to God through Jesus Christ our Lord!”

In Twelve Step recovery the realization of powerlessness over alcohol and drugs (Step One) is followed by coming to believe that a Higher Power can save you from the hopeless insanity of active addiction (Step Two). Clearly there is a radical theological and spiritual difference between coming to believe in Jesus Christ as Lord and coming to believe in a Higher Power. But the dynamic of recognizing personal inability and powerlessness over sin (or addiction), with the concomitant need to believe in and surrender to a Higher Power (or Jesus Christ) captures the ‘conversion’ process present in both Twelve Step recovery and becoming born again.

In the Institutes of the Christian Religion, John Calvin extends the metaphorical use of ‘flesh’ in a nonphysical sense for sinful human nature by referring to the behaviors that proceed from the depravity of the flesh as ‘disease.’ In a discussion of how we are all, without exception, “depraved and given over to wickedness,” Calvin noted that God is pleased to put forth His healing hand to some who “labour naturally under the same disease.” In other sections of the Institutes, he refers to the diseases of evil-speaking, concupiscence, distrust and sin: “Had he not foreseen that his people were constantly to labour under the disease of sin, he never would have appointed these remedies.” Matthew Henry, Charles Spurgeon, Warren Wiersbe and others have also conceived of sinful desires and behavior as disease—with Christ as: “the Great Physician who heals the heart from the sickness of sin.”

Ralph Robinson, a Presbyterian minister in the 1600s, cautioned his readers to watch against sin as they watched against sickness. Noting how many people are careful to avoid eating or drinking anything that would disturb the quiet in their bodies, he asked why they aren’t as cautious of sin? “No sickness is so catching as sin is. Everyone has the root of it, and an inclination to it in their hearts. . . . It is worse than the small pox, worse than the plague. Other diseases will kill the bodies of your children, but sin will kill both body and soul.”

Alcoholism and drug addiction are often accepted as ‘diseases’ in their own right, and said to have no real differences from other diseases such as diabetes. Research on addiction increasingly refers to it as a ‘brain disease.’ In “Addiction is a Brain Disease, and It Matters,” published in the journal Science, Alan Leshner said that recognizing addiction as a “chronic, relapsing brain disorder” would benefit society’s overall health policy and help reduce the costs associated with drug abuse and addiction.

Similarly, in an HBO documentary Addiction, Dr. Nora Volkow, the director of the National Institute on Drug Abuse specifically claimed that addiction was a brain disease: “Drug addiction is a disease of the brain . . . that translates into abnormal behavior.” She added that this leads to an inability to control the drug, because the brain will view its need for the drug with the same intensity as if the person was starving. Brain imaging research done by Dr. Volkow has revealed “neurochemical and functional changes in the brains of drug-addicted subjects that provide new insights into the mechanisms underlying addiction.” In The Science of Addiction, Carleton Erickson said research suggests that continued exposure of the MDS (mesolimbic dopamine system/pleasure pathway) pathway of the brain to a drug leads to changes in nerve function. The changes reach a threshold, which then leads to compulsive substance use over which the individual has impaired control.

However there is a biblical problem with addiction as merely brain disease. In Addictions: A Banquet in the Grave, Ed Welch said: “When we have a disease, we can still be growing in the knowledge of Christ, but addictions are incompatible with spiritual growth.” Genetics and biochemistry can influence human behavior, but they cannot determine it. While addictive ‘disease’ may include actual physiological dysfunction, it is also an “infection of the human heart.” The “translation process” from brain physiology to abnormal behavior passes through the human heart.

Addiction is then simultaneously “an infection of the human heart” and “a disease of the brain.” To emphasize or ignore either aspect of addiction will lead to an incomplete picture of what constitutes addiction. Carleton Erickson attempts to approach this truth from a purely scientific or general revelation perspective in noting that if addiction is a brain disease, then “behavioral therapies probably change brain chemistry.” He then comments that for some people, “spirituality could be a very effective way to do this.”

The morning after Armistice Day his wife found Bill unconscious in the area way of their home. He’d fallen against the door, and was bleeding heavily from a bad scalp wound. He settled hopelessly into a kind of bottomless bingeing. He no longer went out except to replenish his supply. Then an old drinking buddy came by, but declined Bill’s offer to drink. When asked what had got into him, his friend said: “I’ve got religion.”

Getting religion was the last thing Bill was interested in. Yet it was working with his friend. The last he’d heard, the friend was to be committed to the state asylum in Brattleboro, Vermont. “Instead, here he was in Bill’s own kitchen, sober and showing a confidence he hadn’t displayed in years.” He told Bill his story simply, without any attempt to convert him, and then he left. Bill continued to drink, but he was engaged in an “endless interior dialogue with himself.”

Eventually he found his way to Towns Hospital. His friend visited him there and they talked as they had in Bill’s kitchen. When the friend left, Bill fell into a deep depression. There was nothing ahead of him but death or madness. He had reached a state of total, absolute surrender. Without faith or hope, he cried: “If there be a God, let Him show Himself!”

Suddenly my room blazed with an indescribably white light. I was seized with an ecstasy beyond description. . . . Then, seen in the mind’s eye, there was a mountain. I stood upon its summit, where a great wind blew. A wind, not of air, but of spirit. In great, clear strength, it blew right through me. Then came the blazing thought: “You area free man.” . . . . I became acutely conscious of a Presence, which seemed like a veritable sea of living spirit. I lay on the shores of a new world. “This,” I thought, “must be the great reality. The God of the preachers.”

Bill never drank again. He would eventually meet Dr. Bob and together they would form Alcoholics Anonymous. That which is born of the flesh (the physical body) is flesh (depraved and given over to wickedness). The story of Bill’s “white light” experience was taken from Pass It On, an account of how the A.A. message reached the world.

11/27/18

I Must Have Another Drink!

If we suppress the “fundamental idea of God” that lies within us, then God gives us up to the lusts of our heart. There is war between the flesh and the spirit; we don’t do what we want to do; our lives become unmanageable. We are powerless over sin—and if that powerlessness involves mind-altering substances, alcohol or drugs becomes our god. As Paul quotes in a flurry of verses beginning at Romans 3:10: “as it is written: None is righteous, no, not one; no one understands; no one seeks for God. All have turned aside; together they have become worthless; no one does good, not even one. “All have sinned and fallen short of the glory of God.” (Romans 3:23)

Although we are powerless over sin, God has provided a way out through faith in Jesus Christ. And this righteousness is available for all who believe. In his commentary on Romans, John Murray said: “There is no discrimination among believers—the righteousness of God comes upon them all without distinction.” The Old Testament itself (the Law and the Prophets) bears witness to this. In fact, it can be shown that God had this plan for salvation in mind even before the sin of Adam and Eve.

But now the righteousness of God has been manifested apart from the law, although the Law and the Prophets bear witness to it— the righteousness of God through faith in Jesus Christ for all who believe. For there is no distinction: for all have sinned and fall short of the glory of God, and are justified by his grace as a gift, through the redemption that is in Christ Jesus, . . . (Romans 3:21-24)

The root meaning of the Greek word for redemption is to deliver by paying a price. So our deliverance from sin through Jesus Christ is more like a ransom than liberation. We were bought at a price and not simply liberated from the concentration camp of sin and death. So there is a contrast here between the freely given gift of grace and the costliness of the ransom paid by Christ to release us.

Not only have all sinned and fallen short of the glory of God, but all are justified by grace, free of charge, through the redemption in Christ Jesus. “By his grace as a gift” emphasizes the unmerited nature of God’s justification and is the solution to the conclusion of verse 3:20, namely that “by works of the law no human being will be justified.” Nothing we do, not even what we possess as creatures made in His image, can predispose God to cause us to be free from sin and in right relationship with Him. Yet He gives it freely as a gift.

. . . whom God put forward as a propitiation by his blood, to be received by faith. This was to show God’s righteousness, because in his divine forbearance he had passed over former sins. It was to show his righteousness at the present time, so that he might be just and the justifier of the one who has faith in Jesus. (Romans 3:25-26)

Here the gospel and mere recovery take different paths, because of the significance of Christ for salvation. Both the gospel and recovery can acknowledge the powerlessness we have over sin (addiction), but Paul asserts that our release from sin was at the cost of Jesus’ death as an atoning sacrifice. In mere recovery there is no redeeming sacrifice; no ransom paid for the release from addiction. Faith in God to deliver from addiction leads to a liberation from addiction, but not to the redemption that is in Christ Jesus.

This idea of a costly ransom is further asserted in referring to Christ Jesus as a propitiation in verse 25. The Greek word used here is only found one other time in Scripture, in Hebrews 9:5 where it refers to the mercy seat, the covering over the Ark of the Covenant. On the Day of Atonement, Yom Kippur in modern Jewish worship, the high priest would enter into the Holy of Holies and sprinkle the mercy seat with the blood of a sacrifice to make atonement for the sins of all the people (Leviticus 16). The sprinkling of blood over the mantle of the homes of the Israelites was also done so that the angel of death would “pass over” their homes as it brought judgment to Egypt (Ex. 12:1-20). The Passover meal celebrates this deliverance.

So Paul is presenting Jesus Christ as the redeeming sacrifice that takes away the sins of all who believe in him. Our sins are atoned for because of the blood of his sacrifice.

Paul has been unpacking several phrases in these last few verses; and he does so again in verse 3:26. The righteousness of God in verse 21 is noted to be the righteousness of God through faith in Jesus Christ in verse 22. The redemption (ransom) in Christ Jesus noted in verse 24 was specified to be a result of our willingness to believe that he was the true expiatory sacrifice (verse 25). Not only was this to show the righteousness of God because He passed over our former sins (verse 25), but that God did so at this present time, in Christ Jesus (verse 26), because there was no other way. In Jesus Christ alone do we receive forgiveness of our sins and justification from God. Jesus himself was not only righteous, but also the one who declares that all who have faith in him are righteous themselves.

Notice the similarity between the powerlessness over sin noted above and how Bill W. described the powerlessness over alcoholism faced by the alcoholic in the “Step One” essay of Twelve Steps and Twelve Traditions: “Every natural instinct cries out against the idea of personal powerlessness. It is truly awful to admit that . . . we have warped our minds into such an obsession [for destructive drinking] that only an act of Providence can remove it from us.”

In Twelve Step recovery there is a saying that once you are powerless over addiction, continued drug and alcohol use will ultimately lead to jail, institutions, or death. There is no hope for an addict or alcoholic who remains in an active addiction. Ultimately, they will die in their addiction. Some sociologists even liken addiction to indirect suicide. But sometimes, the suicidal impulse is more direct. Here is a quote from “An Inner Truth,” from the AA Grapevine:

One night, I decided that I couldn’t live with alcohol anymore–but I couldn’t live without it. So, I devised a fail-proof plan to take my life. I took a vacuum hose and connected it to the exhaust of my truck, taped and sealed the windows, started the truck, finished my fifth (I wouldn’t want to leave any behind), and prepared to die. I awakened the next morning in my truck, very sick, with an empty fifth, and very much alive. I looked at the gas gauge and there was still a quarter tank of gas left. The key was in the “on” position and the fail-proof plan had failed. The truck died during the night, and I didn’t. Somehow, a few months later, I ended up at an AA meeting sitting across the table from a man who had attempted suicide with a shotgun and blown his face off. He looked across the table at me and said, “Welcome,” and then, “Boy, you look like crap.” Coming from a man without a nose and a lot of facial damage, this statement stuck in my mind.

Proverbs 23:29-35 captures the clear cycle of unmanageability in alcoholism. It explicitly describes the spiral of progressive sin in alcoholism:

Who has woe? Who has sorrow? Who has strife? Who has complaining? Who has wounds without cause? Who has redness of eyes? Those who tarry long over wine; those who go to try mixed wine. Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly. In the end it bites like a serpent and stings like an adder. Your eyes will see strange things, and your heart utter perverse things. You will be like one who lies down in the midst of the sea, like one who lies on the top of a mast. They struck me, you will say, but I was not hurt; they beat me, but I did not feel it. When shall I awake? I must have another drink.

In My Utmost for His Highest (which was used by early members of A.A), Oswald Chambers noted there is something in human nature that laughs in the face of every ideal you have. “If you refuse to agree with the fact that there is vice and self-seeking, something downright spiteful and wrong in human beings, instead of reconciling yourself to it when it strikes your life, you will compromise with it and say it is of no use to battle against it.” So it’s not just that we do wrong things—that we sin, drink or use drugs—but that there is something in human nature that is opposed to our ideals.

There is something within us that seeks to resist the good we want to do. Sinful behavior is an expression of a sinful heart (cf. Mark. 7:20-23; Proverbs. 4:23; 23:7). John Calvin said in The Institutes of the Christian Religion, “The human mind is, so to speak, a perpetual forge of idols.” We dare to imagine a god suited to our own understanding and substitute “vanity and an empty phantom” for the true God. The god whom we have thus conceived inwardly, we then attempt to embody outwardly.

Oswald Chambers said if we repeatedly run after self-serving desires, eventually they become our gods. For the addict and the alcoholic, their drugged state becomes their god. Sin in this sense is wrong being, not wrong doing. It is deliberate, emphatic independence of God:

The revelation of the Bible is not that Jesus Christ took upon Himself our fleshly sins, but that He took upon Himself the heredity of sin which no man can touch. God made His own Son to be sin that He might make the sinner a saint. All through the Bible it is revealed that Our Lord bore the sin of the world by identification, not by sympathy. He deliberately took upon His own shoulders, and bore in His own Person, the whole massed sin of the human race—“He hath made Him to be sin for us, who knew no sin,” and by so doing He put the whole human race on the basis of Redemption. Jesus Christ rehabilitated the human race; He put it back to where God designed it to be, and anyone can enter into union with God on the ground of what Our Lord has done on the Cross.

Remember that in his divine forbearance, God passes over our former sins—even those we don’t remember doing while in a blackout. This shows His righteousness, for He is the justifier of those who have faith in Jesus (Romans 3:25-26).

10/19/18

Feuding Ideologies, Part 2

In the first paragraph of “Dying To Be Free,” you are introduced to Patrick, a smiling 25 year-old who had just completed a 30-day drug treatment center. Among his possessions was “a talisman he’d been given by the treatment facility: a hardcover fourth edition of the Alcoholics Anonymous bible known as ‘The Big Book.” It pages were full of highlights and Post-It notes. He was said to be a “natural” 12-step convert. Four days later, his father found him dead of an overdose.

As you read about Patrick’s struggles with addiction, you get a picture of how he and his parents tried to help him establish sobriety. There is a reference to his residential treatment stay as a “30-day wonder,” where he received a crash course on the tenets of the 12-steps. “Staff at the center expected addicts to reach a sort of divine moment but gave them few days and few tools to get there.” In Part 1 of this article, I addressed concerns that an underlying ideology of addiction as a strictly biomedical disease contributed to a biased, distorted picture of addiction treatment in the U.S. by the author of “Dying To Be Free.” Here we will look at how he also misrepresents the recovery philosophy and history of A.A.

There is a preponderance of religious or magical rhetoric when describing 12 Step, abstinent-based change in “Dying To Be Free.” Already we’ve noted the main text of Alcoholics Anonymous, also called Alcoholics Anonymous, was referred to as a talisman and a “bible.” Patrick was a “natural 12-step convert.” Another reference described the A.A. Big Book as being the size of a hymnal, with an appeal to faith made in “the rat-a-tat cadence of a door-to-door salesman.” Addicts at a certain treatment center were supposed to “reach a sort of divine moment” in treatment or recovery. Entering the drug treatment system, which is dominated by the principles of abstinence embedded in the 12-Steps, was said to require a “leap of faith.”

In a description of the Grateful Life Treatment Center in northern Kentucky, it was noted that the wall above the desk of the center’s intake supervisor had a “Jesus bumper sticker.” Why add that detail unless you are trying to capture the scene in a particularly religious way? When describing treatment facilities modeling themselves on the 12 Steps, not only were recovering addicts said to be cheap labor, they were said to provide the “evangelism” to shape the curricula of the facilities. A resident of Grateful Life was noted to be “as close to a true believer as the program produces.”

At one point, the author of “Dying To Be Free,” Jason Cherkis, said AA came out “evangelical Christian movements.” More accurately, there is a clear historical connection between a nondenominational Christian movement popular during the 1920s and 1930s called the Oxford Group and Alcoholics Anonymous. The two cofounders of A.A., Bill W. and Dr. Bob met as a result of their personal association with the Oxford Group. A.A. approved books, such as Pass It On, Doctor Bob and the Good Oldtimers and AA Comes of Age freely acknowledge the connection and give further details about it. However, a crucial distinction made by A.A. within its 12 Steps is glossed over by Cherkis and others, namely the spiritual, not religious understanding of God and recovery embodied in the Twelve Steps.

Drawn from the thought of the American psychologist, William James, this distinction between religious and spiritual experience seems to underlie the widespread sense of generic spirituality in American culture today. The Varieties of Religious Experience (VRE) by James had a fundamental influence on Bill W., the formulation of the Twelve Steps and the spirituality based upon them. In VRE James made a distinction between institutional and personal religion. Worship, sacrifice, ritual, theology, ceremony, and ecclesiastical organization were the essentials of what he referred to as institutional religion.

Personal religion/spirituality for his [James’] purposes was defined as “the feelings, acts, and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine.” In the broadest sense possible, this spirituality consisted of the belief that there was an unseen order to existence, and supreme good lay in harmoniously adjusting to that order.

Whether their disregard of the spiritual, not religious distinction is intentional or not, Cherkis and others give an incomplete and biased picture of Twelve Step recovery when they fail to note it. The very heart of Twelve Step spirituality is the permissibility of the individual to formulate a personal understanding of their “god.” So what unites members of Twelve Step groups like A.A. is the diversity of religious and spiritual belief permitted—even to accepting a lack of belief. I’ve written several other articles on the similarities and differences between the spirituality of the Twelve Steps and religious spirituality on this website. There are three particular articles that discuss the influences on the spiritual, not religious distinction of Twelve Step recovery: “What Does Religious Mean?”, “Spiritual Not Religious Experience” and “The God of the Preachers.”

Another example of how “Dying To Be Free” misrepresents the recovery philosophy of A.A. is the following. While introducing a discussion of Charles Dederich and the origins of Synanon, Cherkis said Dederich and others took a “hard line message” from some of Bill W.’s written philosophy. Cherkis wrote: “Those who can’t stick with the program are ‘constitutionally incapable of being honest with themselves,’ reads the Big Book. ‘They seem to have been born that way.’” The two selective quotes were from the first paragraph of chapter five, “How It Works,” in Alcoholics Anonymous. Notice how the context of the complete paragraph changes your understanding of what Bill W. said in his “philosophy”:

Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.

As Cherkis began to discuss the history of the expansion of drug treatment facilities in the 1960s, he quoted Nancy Campbell, a professor at Rensselaer Polytechnic Institute, as saying: “The history of 12-step came out of white, middle-class, Protestant people who want to be respectable.” She added that it offered community and belonging that was predicated on being normal, respectable and having a stake in mainstream society. Campbell may be a historian, but she seems to have a distorted view of the early history of 12 Step recovery in A.A.

From the sociological perspective of labeling theory A.A. and other organizations based on their 12 Steps, like N.A. (Narcotics Anonymous), can at least be partially seen as social movements that seek to combat negative images associated with socially deviant drinking or drugging behavior, “in effect denying that their actions make them deviants.” This applies the idea of tertiary deviance, first described by John Kituse in: “Coming Out All Over: Deviants and the Politics of Social Problems.” Kituse noted that some people stigmatized as deviant (here as alcoholics) “rebel against their labels and attempt to reaffirm their self-worth and lost social status.” The above quote and reference to Kituse is found in a standard social science textbook by Clinard and Meier, Sociology of Deviant Behavior. So part of Campbell’s assessment of 12 Step groups as social movements seeking to offer community and belonging, with a “stake in mainstream society” is accurate. However, the quote attributed to her glosses over the early history of A.A., which was the beginning of the 12 Step movement.

A.A. celebrates the anniversary of its founding on June 10, 1935. That was in the midst of the Depression. Bill W. and his wife Lois were living then in a house owned by her father on Clinton Street in New York City. In September of 1936, Lois’s father died and the house was taken over by the mortgage company, which allowed them to stay on for a small rental. In the midst of the Depression, they didn’t want the house to be empty. While struggling with “their acute poverty,” Bill was almost persuaded to accept a position as a paid alcoholism therapist at Towns Hospital, where he himself had been treated several times. He eventually declined the offer.

Almost two and a half years after the founding of A.A., Bill W. was jobless and Dr. Bob was in danger of losing his house. In 1938, through the charity of John D. Rockefeller Jr., $5,000 was approved for a fund that would pay off Dr. Bob’s mortgage and allow a weekly draw of $30 for each of them. Rockefeller told one of his associates afterwards: “But please don’t ever ask me for any more.” In 1939, as the Depression eased, the mortgage company was able to sell the Clinton Street house and Bill and Lois became homeless. They lived “as vagabonds,” as various places for two years. Bill W. and Lois eventually led a respectable, middle class lifestyle, but that wasn’t what it was like for them in the beginning of A.A.

This history is found in Pass It On, published by Alcoholics Anonymous World Services, Inc. In the early days of A.A., Bill W. repeatedly turned down offers to professionalize his work with A.A. This doesn’t entirely sound like a movement trying to gain white, middle class respectability. The Traditions of A.A., formally adopted in July of 1950, articulated this philosophy of non-professionalism and a focus on helping other alcoholics in the fifth, sixth and eighth Traditions.

Tradition Five Reads: “Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.” Tradition Six reads: “An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.” Tradition Eight reads: “Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.”

Alternative addiction treatment ideologies regularly attack A.A. as “religious,” ignoring or rejecting the spiritual-religious distinction A.A. made within the Twelve Steps from the very beginning. The abstinent-based recovery philosophy embedded in the Twelve Steps seems to be the primary target of these critiques. I see the same tendency in “Dying To Be Free.” The first part of this article addressed the biased portrayal of abstinent-based addiction treatment by Jason Cherkis in “Dying To Be Free.” The third and final part will address how it skimmed over the problems with MAT, specifically Suboxone.

10/16/18

Feuding Ideologies, Part 1

In August of 2017, the now former Health and Human Services Secretary, Tom Price, said he didn’t think it was necessary to declare the opioid epidemic to be a national emergency. This was despite the president’s own opioid commission recommending it as the “first and most urgent recommendation.” Two days later, the President reversed Price’s statement, saying: “The opioid crisis is an emergency, and I’m saying officially right now it is an emergency.” The response was mixed. While President Trump’s announcement could be used to help free up federal resources and help to prioritize responses to the disaster, it could also permit the administration to push for new sentencing legislation in order to get “tough on crime” related to drug use.

What isn’t disputed is that the U.S. does have a serious opioid problem and something needs to be done about it. Drug overdose is the leading cause of death in Americans under the age of fifty. Forecasts by STAT News are the annual death rate will increase by at least 35 percent by 2027. The CDC reported that from 2002 to 2015 there was a 5.9-fold increase in the overdose deaths from heroin and non-methadone synthetic opioids.

The latest statistics for the U.S. opioid epidemic is now available in the 2016 National Survey on Drug Use and Health (NSDUH). Among the myriad of statistics reported there was news that heroin users increased 230% from 2002 to 2016, while heroin deaths increased 630%. An estimated 948,000 people aged 12 or over reported they used heroin in the past year. That translates to .4% of the country’s population. There were also an estimated 11.5 million people who misused pain relievers in the past year, 4.3% of the population aged 12 or over. Combined, there are 11.8 million people who misused opioids, 4.4% of the population, in 2016.

The 2016 NSDUH Report can be accessed here. A shorter, graphic-based report of key findings, including those noted above, is here.

One of the treatment approaches often touted to address the opioid crisis is medication-assisted treatment (MAT) with Suboxone. In January of 2015, Jason Cherkis wrote “Dying To Be Free.” His subtitle asked why we weren’t using a treatment for heroin addiction—Suboxone—that actually worked. The opioid problem in Kentucky was the focus of his article, which I found to be rhetorically persuasive and well written. You are introduced to individual after individual who wouldn’t or couldn’t use Suboxone and ended up dead from an eventual overdose.

“Dying To Be Free” was a finalist for a Pulitzer in 2016 for its “deeply researched reporting on opioid addiction” that showed how many drug overdose deaths could have been prevented. The cover letter submitted for its entry for the Pulitzer by The Huffington Post said it triggered a series of state and federal policy changes that rejected abstinence for opioid misuse and embraced medication-assisted treatment. “‘Dying To Be Free’ offered readers an immersive experience that included audio and video documentaries and photo and data displays.”

This was not fake news. “Dying to Be Free” captured the agony of individuals and families who struggle with opioid misuse. But it also made abstinence-based approaches to treatment and recovery a bogeyman responsible for many of the unnecessary deaths from opioid overdoses. The rhetoric of the article was a straw man attack on abstinent-based treatment while it extolled MAT. Its biomedical treatment bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction. Nor did it tell the whole story behind Suboxone. It also misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous. Here’s what I mean.

In the last paragraph of his second chapter, Cherkis said: “There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer.” This succinctly captures the problem as he sees it with existing treatment approaches to the opioid crisis. Heroin addiction is a medical disease and should be treated as a medical disease. Modern medicine has a scientific treatment for heroin addiction that is resisted because of stigma, a deep-rooted adherence to self-help, and the criminalization of heroin addiction. If you question or oppose MAT, you are apparently mired in a kind of scientific dark age.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls.

Dr. Mary Kreeft, one of the pioneers of methadone maintenance, was liberally quoted to support the medical model of addiction. She noted how opioid addiction alters multiple regions in the brain, including those that regulate reward, memory, learning, stress, hormonal response and stress sensitivity. According to Dr. Kreeft, after a long cycle of opiate addiction, a person needs specific medical treatment. Some people may be OK in time. But “the brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreeft said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

This is a rigid, strict medical model of opioid addiction. And it gives a mixed message regarding whether or not the individual will ever be able to stop taking Suboxone or methadone. Neither drug, said Cherkis, is a miracle cure. But they buy addicts time to fix their lives, seek counseling and allow their brains to heal. So far, so good. But here comes the caution: Doctors recommend tapering off the medication cautiously. The process could take years, as addiction is a chronic disease and effective therapy takes time. Then comes the typical analogy of the pure medical model of addiction:

Doctors and researchers often compare addiction from a medical perspective to diabetes. The medication that addicts are prescribed is comparable to the insulin a diabetic needs to live.

There is no mention of neuroplasticity—the brain’s ability to reorganize itself by forming new neural connections. “Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.”

Jeffrey Schwartz and Rebecca Gladding use an almost identical description of neurological action to that given above by Dr. Kreeft to describe how to change the brain; to modify bad habits (including addiction) and unhealthy thinking. In You Are Not Your Brain, they describe how we teach our brains to act in unhealthy ways. The brain does not distinguish between beneficial and destructive habits, “it just responds to how you behave and then generates strong impulses, thoughts, desires, cravings, and urges that compel you to perpetuate your habit, whatever it may be.”

Clearly, the brain can exert a powerful grip on one’s life—but only if you let it. The good news is that you can overcome the brain’s control and rewire your brain to work for you by learning to debunk the myths it has been so successfully selling you and by choosing to act in healthy, adaptive ways.

Neuroplasticity, as described by Schwartz and Gladding, does not reject Kreeft’s neurological description of addiction. But it does say it isn’t the whole story. An ideology of addiction as a purely biomedical condition seems to permeate “Dying To Be Free.” Addiction, when conceived strictly as a brain disease, rejects or ignores the non-scientific construct of mind. If we are conceived as only biological beings, then addiction is explained and treated within a biomedical worldview. Any treatment approach to addiction not based on this premise is therefore faulty.

Drug treatment facilities were said in “Dying To Be Free” to “generally” fail to distinguish between addictions. They have a one-size-fits-all approach. Addicts in residential treatment experience a “hodgepodge” of drill-instructor tough love and self-help lectures. Programs appear simultaneously excessively rigid and wildly disorganized. “And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids.”

After describing two older, drug treatment programs with a therapeutic community model of care that used coercive techniques—Synanon and Daytop (Drug Addicts Yield TO Persuasion)— he said:

The number of drug treatment facilities boomed with federal funding and the steady expansion of private insurance coverage for addiction, going from a mere handful in the 1950s to thousands a few decades later. The new facilities modeled themselves after the ones that had long been treating alcoholics, which were generally based on the 12-step methodology. Recovering addicts provided the cheap labor to staff them and the evangelism to shape curricula. Residential drug treatment co-opted the language of Alcoholics Anonymous, using the Big Book not as a spiritual guide but as a mandatory text — contradicting AA’s voluntary essence. AA’s meetings, with their folding chairs and donated coffee, were intended as a judgment-free space for addicts to talk about their problems. Treatment facilities were designed for discipline.

In support of this claim, Cherkis referred to a 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University. It apparently was a reference to “Addiction Medicine: Closing the Gap between Science and Practice.” He said the study concluded the U.S. treatment system was in need of a “significant overhaul” and questioned whether the low levels of care received by addiction patients constituted a from of medical malpractice.

While medical schools in the U.S. mostly ignore addictive diseases, the majority of front-line treatment workers, the study found, are low-skilled and poorly trained, incapable of providing the bare minimum of medical care. These same workers also tend to be opposed to overhauling the system. As the study pointed out, they remain loyal to “intervention techniques that employ confrontation and coercion — techniques that contradict evidence-based practice.” Those with “a strong 12-step orientation” tended to hold research-supported approaches in low regard.

The Columbia University study did state a significant overhaul was needed in current treatment approaches; and it raised the question if the insufficient care received by addiction patients constituted “a form of medical malpractice.” It also pointed to the need for medical schools to “educate and train physicians to address risky substance use and addiction.” Unsurprisingly, it went on to say that all aspects of stabilization and treatment with addictions should be managed by a physician “as is the case with other medical diseases.” Remember that the Columbia study and Cherkis were both advocating for a physician-centered, medical model approach to addiction treatment.

However, I couldn’t find where it was supposed to have said the majority of front-line treatment workers were low-skilled and poorly trained. There was a section stating that physicians and other health professionals should be on the front line addressing addiction. Then it said: “Paraprofessionals and non-clinically trained and credentialed counselors can provide auxiliary services as part of a comprehensive treatment and disease management plan.”

It did not say the majority of front-line treatment workers were low-skilled and poorly trained “incapable of providing the bare minimum of medical care.” Yet in the case study examples found in “Dying To Be Free,” that is what Cherkis presented. The Columbia study did cite another study, which found that recovering support staff had little enthusiasm for evidence-based practices. “They also were more likely to support intervention techniques that employ confrontation and coercion–techniques that contradict evidence-based practices.” But these paraprofessionals only made up “24 percent of the treatment provider workforce.”

Cherkis seems to have mis-remembered what the Columbia study actually claimed in this matter. I wonder if, because of his commitment to a strictly medical model ideology for opiate treatment, he was reading into the study. His quote above supported the description of the treatment facilities he highlighted in his article, but wasn’t found by me in the article he cited on the Columbia study.

Another example of how his treatment ideology distorted his portrayal of Suboxone treatment was with how he described Hazelden’s Suboxone treatment program. “Dying To Be Free” mentioned that Hazelden, now the Hazelden Betty Ford Foundation, developed its own Suboxone treatment program for opioid addicts. But it failed to note this wasn’t accompanied by a rejection of “Twelve Step practices.” Within “The History of Hazelden,” on the Hazelden Betty Ford Foundation website, was the statement of how it “integrates the cornerstone Twelve Step practices of mutual support along with multidisciplinary clinical care, evidence-based therapies and the latest research in brain science.” Why weren’t there some case study examples from Hazelden in “Dying To Be Free”?

The facilities Cherkis highlighted in Kentucky were not representative of abstinent-based addiction treatment centers in the U.S.; ones that use the 12 Steps to structure their treatment program. In reading “Dying To Be Free” I see an underlying ideology of conceiving and treating addiction, specifically opiate addiction, through a strict biomedical lens. That is not the whole story of addiction. As a result, the rhetoric of the article constituted a straw man attack on abstinent-based treatment while it extolled MAT. This bias presents readers with an implied choice, a dichotomy, between Suboxone as an MAT for addiction and 12 Step, abstinent-based treatment. Ironically, Hazelden, an historically important treatment center that pioneered 12 Step, abstinence-based treatment, did not choose MAT over the 12 Step-based treatment, but combined the two. But you don’t get that information in “Dying To Be Free.”

Part 2 and Part 3 of this article will look at how “Dying To Be Free” misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous; and skimmed over the problems with MAT, specifically Suboxone.

08/17/18

Ask, Seek, Knock

Mount of Beatitudes and the Sea of Galilee; credit: BiblePlaces.com

When you pray, what should you pray for? Should you pray specifically and persistently for what you need? In his essay on Step Eleven in Twelve Steps and Twelve Traditions, Bill W. said this type of prayer could be done, “but it has hazards.” The problem is the thoughts that seem to come from God may not really be His answers. They may be “well-intentioned unconscious rationalizations.” Bill warned the person who tried to run their life by this kind of prayer could create havoc without meaning to.

He may have forgotten the possibility that his own wishful thinking and the human tendency to rationalize have distorted his so-called guidance. With the best of intentions, he tends to force his own will into all sorts of situations and problems with the comfortable assurance that he is acting under God’s specific direction. Under such an illusion, he can of course create great havoc without in the least intending it. . . .Our immediate temptation will be to ask for specific solutions to specific problems, and for the ability to help other people as we have already thought they should be helped. In that case, we are asking God to do it our way. . . . As the day goes on, we can pause where situations must be met and decisions made, and renew the simple request: “Thy will, not mine be done.”

If you want biblical guidance on how to pray, you could turn to the Sermon on the Mount (Matthew 7:7-11), where Jesus said we should ask, seek and knock. If human fathers know how to give good gifts to their children, “how much more will your Father who is in heaven give good things to those who ask him!”

⁷“Ask, and it will be given to you; seek, and you will find; knock, and it will be opened to you. ⁸For everyone who asks receives, and the one who seeks finds, and to the one who knocks it will be opened. ⁹Or which one of you, if his son asks him for bread, will give him a stone? ¹⁰Or if he asks for a fish, will give him a serpent? ¹¹If you then, who are evil, know how to give good gifts to your children, how much more will your Father who is in heaven give good things to those who ask him! (Matthew 7:7-11)

Leon Morris said in his commentary on Matthew the central point of these verses is that prayer to a loving Father is effective. “The point is not that human persistence wins out in the end, but that the heavenly Father who loves his children will certainly answer their prayer.” So when we ask, seek and knock we can confidently believe God will answer our prayer, because Your Father knows what you need before you ask him” (Matthew 6:8).

Craig Blomberg, in his commentary on Matthew, said Jesus presupposed his listeners would remember his teaching on the Lord’s Prayer when he told them to ask, seek and knock. Jesus said we should pray for God’s will to be done “on earth as it is in heaven” (6:7-13). The asking, seeking, knocking in 7:7-11 highlight the effectiveness of prayer and not some name-it-and-claim-it mantra that compels God to gave us what we want when we want it. Blomberg added:

Those who today claim that in certain contexts it is unscriptural to pray “if it is the Lord’s will” are both heretical and dangerous. Often our prayers are not answered as originally desired because we do not share God’s perspective in knowing what is ultimately a good gift for us.

James confirmed this when he said: “You ask and do not receive, because you ask wrongly, to spend it on your passions” (James 4:3). Sometimes our own wishful thinking will lead us to ask wrongly. Bill W. agreed: “We discover that we receive guidance for our lives to just about the extent we stop making demands upon God to give it to us on order and on our terms.”

In Matthew 6:9-10 Jesus makes the same point—that God will certainly answer our prayer because He is a Father who loves His children—by approaching it in a different way. Here he uses the analogy of a human father and son and asks his audience if they would give their own son a stone if he asked for bread or a serpent if he asked for a fish. The rhetorical questions imply a negative answer: of course they wouldn’t! No human parent would treat a son this way. Reasoning from the lesser human father to God as the greater Heavenly Father, Jesus said if an “evil” (morally bankrupt or degenerate) human father would not think of treating his son in this way, certainly God would not so mistreat His children.

Returning now to Bill W. and his essay on Step Eleven, he said those in A.A. who have come to make regular use of prayer “would no more do without it than [they] would refuse air, food, or sunshine.” Just as the body would fail if it did not receive nourishment, so will the soul. “Pray and meditation are our principle means of conscious contact with God.”

In A.A. we have found that the actual good results of prayer are beyond question. They are matters of knowledge and experience. All those who have persisted have found strength not ordinarily their own. They have found wisdom beyond their usual capability. And they have increasingly found a peace of mind, which can stand firm in the face of difficult circumstances.

Those who were reluctant to pray because they did not see any evidence of “a God who knew and cared about human beings” were likened to a scientist who refused to perform a certain experiment “lest it prove his pet theory wrong.” When they finally tried the experiment of prayer, they felt and knew differently. “It has been well said that ‘almost the only scoffers at prayer are those who never tried it enough.’”

In the A.A. Big Book, Alcoholics Anonymous, Bill W. wrote about putting prayer into action with Step Eleven. He suggested you begin each day by considering your plans for the day. First, you should ask God to direct your thinking, “especially asking that it be divorced from self-pity, dishonest or self-seeking motives.” Be careful to never pray for your own selfish ends. Your thought life will be placed on a higher plane when it is cleared of wrong motives.

As we go through the day we pause, when agitated or doubtful, and ask for the right thought or action. We constantly remind ourselves we are no longer running the show, humbly saying to ourselves many times each day, “Thy will be done.”

So ask, seek, and knock. Everyone who asks receives, and the one who seeks finds. God knows what you need even before you ask. And if you ask wrongly, seeking what you want and not what He knows you need, He won’t give you a stone or a snake. Rather, He will give you the bread and fish you need because he is the Father who gives good gifts. “Thy will, not mine be done.”

11/21/17

Cunning, Baffling, Powerful

Vincent Dole was one of the three physicians who originated methadone as a maintenance drug treatment for heroin addiction in the 1960s. Rather unexpectedly, he was asked to serve as a Class A, non-alcoholic, trustee for the General Service Board of Alcoholics Anonymous. He thought they had made a mistake so before accepting the position, he discussed his research into “chemotherapy for narcotic addiction” with executives of the A.A. Fellowship. They didn’t see any problem or conflict of interest with his appointment and Dr. Dole served as a trustee for A.A. for eleven years, from April of 1965 until April of 1975.

At one point in his tenure as a trustee, he served as a co-chair for the General Service Board. In his farewell letter to the A.A. GSO, printed in the August-September issue of Box 4-5-9, the newsletter from the General Service Office of A.A., he said he would always remain identified with A.A. “My heart is with the Fellowship.”

Like most in A.A., I have gained more in the association than I have been able to give. Especially, it has been a privilege to witness the power of love when focused and unsentimental. I have seen that: Salvation is found in helping others; help stems from knowledge, humility, compassion, and toughness; success is possible.My greatest concern for the future of A.A. is that the principle of personal service might be eroded by money and professionalism. Fortunately, most of the membership of A.A., especially the oldtimers, know that A.A. cannot be commercialized. It is not a trade union of professional counselors or an agency hustling for a budget. The mysterious wisdom of A.A. will discover how to cooperate in reaching out to sick alcoholics while maintaining its Traditions.

In a 1991 article he wrote for the journal Alcoholism, “Addiction as a Public Health Problem,” Dr. Dole said that throughout his time as a trustee he was puzzled by why he specifically was asked to serve. He ended by assuming he had been “brought in as a smoke alarm, a canary in the mine” to guard against “the Fellowship being distorted by aggressive person with dogmatic opinions.” Then, in the late 1960s, he believed a more specific reason emerged, not long before Bill W.’s death. An excerpt from that article is available here: “The Methadone/AA Link.”

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Dr. Dole went on to say he unsuccessfully sought to find that analogue in his laboratory until it closed in 1991. But he thought the work had just begun. Other laboratories and investigators would continue to work on the analogue problem. “With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.”

Since Dr. Dole made that optimistic prediction, several different medications have been used as a harm reduction strategy for individuals with alcohol dependence or alcohol use disorders. Two opioid antagonists, nalmefene and naltrexone and three drugs acting on the gamma-aminobutyric acid (GABA)ergic system (baclofen, acamprosate and toprimate) has been used formally or informally to reduce alcohol consumption or maintain abstinence. Recently in the journal Addiction, Palpacuer et al. did a meta-analysis of 32 double-blind randomized controlled trials of these five medications. The studies were published between 1994 and 2015, and had a combination of 6,036 patients between them. They concluded:

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

There was no evidence of any significant reduction in serious adverse events or mortality. Studies that sought to assess the efficacy of these medications as maintenance drugs, similar to how methadone is used, “were inadequate to investigate” whether they reduced serious adverse events. “In addition, any pharmacological approach that might benefit patients by reducing their alcohol consumption might also harm them because of safety issues.” As a result, the researchers advocated for long-term mega-trials exploring health outcomes.

To conclude, our results suggest that no treatment currently has high-grade evidence for pharmacologically controlled drinking in the treatment of patients suffering from alcohol dependence or alcohol use disorders. At best, some showed low to medium efficacy in reducing drinking, but across a range of studies with a high risk of bias. Although based on all available data in the public domain, this meta-analysis found no evidence of any benefit of the use of drugs aiming for a controlled drinking strategy on health outcomes. We invite researchers and stakeholders to set up a coherent agenda to demonstrate that pharmacologically controlled drinking can be translated into genuine harm reduction for patients. From the clinical perspective, while this new approach is often presented as a ‘paradigm shift’ in terms of therapeutics, doctors and patients should be informed that the critical examination of the pros and cons of the evidence clearly questions the current guidelines that promote drugs in this indication.

Reporting for The Guardian, Sarah Boseley further noted that one of the reasons for the inconclusive findings in Palpacuer et al. was because of the high drop out rates in the studies. “So many people dropped out of the trials that 26 of the 32 studies – 81% of them – had unclear or incomplete outcome data.” The lead author for the study, Clément Palpacuer, said the report did not mean the drugs weren’t effective. “It means we don’t yet know if they are effective. To know that, we need more studies.” There have also been concerns raised about the drugs by some studies already.

Bosley cited Fitzgerald et al., a review of the trial evidence used to approve nalmefene for use in the NHS. The researchers said at best, there was only modest evidence of efficacy in reducing alcohol consumption. This was despite stacking the deck in how the data was analyzed for approval of the drug.

Important weaknesses in nalmefene trial registration, design, analysis and reporting hamper efforts to understand if and how it can contribute to treating alcohol problems in general practice or elsewhere. The efficacy of nalmefene appears uncertain; a judgement of possible limited efficacy in an unusually defined and highly specific post‐hoc subgroup should not provide the basis for licensing or recommending a drug.

There are issues noted with baclofen as well. A co-author of Fitzgerald et al. noted one French study raised concerns with the safety of baclofen, with more deaths in the treatment group (7 of 162) than the placebo group (3 of 158). A further study by France’s medicines safety agency drew attention to additional adverse effects: “In particular, the risk of intoxication, epilepsy and unexplained death [on the death certificate] increases with the dosage of baclofen.” See “Sure Cure for Drunkenness” and “A ‘Cure’ for Alcoholism” and “The End of Alcoholism?” Part 1, Part 2 and Part 3 for more concerns with baclofen and nalmefene.

Vincent Dole’s search for a methadone analogue or adjunctive chemotherapy for alcoholism is unlikely to be successful. As Carleton Erickson pointed out in The Science of Addiction, alcohol is different than other drugs. He said: “Unlike other drugs, alcohol has no specific receptor to activate in the brain.” Cocaine works on the dopamine transporter. Heroin and other opioids work on the opioid receptor; and marijuana works on the cannabinoid receptor. “Alcohol is known to affect the GABA receptor, the NMDA receptor, and probably others.”

There isn’t a hand-in-glove fit between a receptor and alcohol as there is with the opioid receptor and heroin or other opioids. So there isn’t a medication that can single handedly block alcohol as there is with heroin and other opioids. As Bill W. knew from personal experience, alcohol is cunning, baffling and powerful.

07/7/17

More Equal Therapies than Others, Part 2

In his introduction to ”The Doctor’s Opinion” in the A.A. Big Book, Bill W. said A.A. favored initial hospitalization for the alcoholic who was “jittery or befogged.” It was imperative that the person’s brain was cleared so he then had a better chance “of understanding and accepting what we had to offer.” The reason to include Dr. Silkworth’s endorsement in Alcoholics Anonymous was to document a “medical estimate” of the A.A. 12-Step plan of recovery. “Convincing testimony must surely come from medical men who have had experience with the sufferings of our members and have witnessed our return to health.” But that was almost eighty years ago; and there have been some radical changes in the receptiveness of 12-Step recovery.

In modern addiction treatment there are a growing number of voices saying A.A.’s 12-Step approach should either be taken out of the treatment game or sidelined as a “recovery support service” (RSS) instead of being an integral part of the addiction treatment process. However, it would restrict or bench a valuable asset to addiction recovery. The rationales given for this generally follows two lines of argument.

One way is to portray A.A. and other 12-Step groups as religious or cultish in nature. This distortion stems from the secularization of American culture since the late 1930s when A.A. began, as well the failure to make a distinction between spiritual and religious consistent with 12-Step philosophy. See “Spiritual not Religious Experience” for a discussion of this distinction and a response to the accusation that the spiritual nature of A.A. disqualifies it from being used within addiction treatment. The second route is to suggest the 12-Step approach does not fit with the modern medical model of addiction treatment.

In the first ten years of A.A.’s existence the fellowship became convinced that organizationally it had to permanently remain nonprofessional. This was eventually formalized in Tradition Eight. Concurrent with that realization, was the origin of what would be called the Minnesota Model of addiction treatment. The Hazelden Foundation (now the Hazelden Betty Ford Foundation) blended professional and trained nonprofessional staff within a treatment approach based on the 12-Step philosophy of A.A. Throughout the 1950s, Hazelden honed its treatment model on three working principles.

First, alcoholism was seen as a primary condition and not just a symptom of an underlying disorder. Second, alcoholism was a disease and should be treated as such. The American Medical Association (AMA) officially identified alcoholism as a disease in 1956. Third, following the A.A. idea of the alcoholic suffering physically, mentally and spiritually, alcoholism was said to be a multiphasic illness. “Therefore treatment for alcoholism will be more effective when it takes all three aspects into account.” Abstinence was an integral goal of treatment.

These principles set the stage for a model that expanded greatly during the 1960s—one that has been emulated worldwide and has merged the talents of people in many disciplines: addiction counselors, physicians, psychologists, social workers, clergy, and other therapists. These people found themselves working on teams, often for the first time. And what united them was the notion of treating the whole person—body, mind and spirit.

Cracks began to appear in the dominance of the Minnesota Model of addiction treatment even as its hegemony grew in the 1960s. Methadone maintenance as a treatment for heroin addiction arose in the early 1960s. In the 1980s, the biological model of psychiatry began its ascendency and in 1991 the AMA took the further step of endorsing a dual classification of alcoholism as both a psychiatric and a medical disease. In 1992 SMART Recovery began. “SMART Recovery is based on scientific knowledge, and is intended to evolve as scientific knowledge evolve.” In 1994 Moderation Management became a self-help group for individuals who wanted to moderate, not abstain from alcohol.

Addiction professionals developed diverse alternatives to addiction treatment centered on 12-step philosophy. Stanton Peele developed Life Process Program as an alternative to 12-Step treatment, which he now offers as an online program. Marc Lewis wrote The Biology of Desire, refuting the medical view of addiction as a brain disease. He conceived it as an extreme form of learning.

Lance Dodes wrote The Sober Truth, purportedly debunking the bad science behind 12-Step programs and the Rehab industry. It claimed to be an expose of Alcoholics Anonymous, Twelve Step programs and the rehab industry—how “a failed addiction-treatment model” came to dominate America.

David Sinclair developed the Sinclair Method, which conceived of alcoholism as a learned behavior, one that can be removed by the behavior modification principle of extinction. “The solution discovered by Sinclair effectively means you have to drink yourself sober!” And there are others. But the medical model, although it has been modified, remains supreme in addiction treatment.

In the 1990s, a movement began in medicine to develop evidence-based practices (EBP). A widely accepted definition of EBP by Dr. David Sackett is that EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” When applied to addiction treatment, the principle is generally referred to as evidence-based treatment (EBT). The National Institute on Drug Abuse (NIDA) simply referred to EBTs as treatment approaches “that have an evidence base supporting their use.” The website GoodTherapy.org elaborated, saying that EBT was “treatment that is backed by scientific evidence.” This referred to extensive research, which has been documented and demonstrated to be effective on a particular treatment.

Consistent with this understanding, NIDA listed a manualized Twelve Step based treatment model called Twelve Step Facilitation (TSF) as an evidence-based behavioral therapy. TSF actively seeks to engage substance abusers in becoming involved in 12-Step groups, “thereby promoting abstinence.” However, a writer and researcher for Handshake Media, Laurel Sindewald, concluded in her article, “AA Is not Evidence-Based Treatment,” that NIDA wrongly listed TSF as evidence-based.

In Part 1 of this article, “More Equal Therapies than Others,” is a description of TSF and a discussion of how Sindewald’s critique wrongly and inconsistently grouped A.A. and other 12-Step groups with treatment approaches like the Minnesota Model and TSF that use 12-Step philosophy. Her provocative title is the result of mistakenly grouping A.A. and treatment approaches based on 12-Step philosophy together; and then illegitimately transferring her critique of these 12-step treatment approaches to A.A. A.A. sees itself as a fellowship and not a treatment. Here we will briefly look at how Sindewald’s narrowing of the NIDA sense of “evidence-based treatment” allowed her to conclude TSF was not evidence-based.

As was described in Part 1, Sindewald gave a biased description of 12-Step philosophy, stating it viewed addiction as merely “a spiritual disease born of defects of character.” Twelve Step groups supposedly said they were the only cure, “involving faith in a higher power, prayer, confession, and admission of powerlessness.” Contrasted with the NIDA definition of addiction as a disease of the brain, she asked how TSF as a professional medical treatment could be based on an understanding of addiction as a spiritual disease. Note the rhetorical sleight-of-hand in how she conveniently left out the A.A. and 12-Step understanding of addiction as a physical, mental and spiritual illness/disease.

Another place Sindewald used the same tactic was where she defined evidence-based. “In this article, I define ‘evidence-based’ to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples.” Note how her sense of “evidence-based” is more restrictive than NIDA, GoodTherapy.org and even Sackett’s widely acknowledged sense of evidence-based practice for medicine. Her criteria seem to be even more restrictive than the American Psychological Association’s criteria for well-established “empirically validated treatment” in the “APA Task Force on Promotion and Dissemination of Psychological Procedures” Refer to Table 1 for the criteria.

Gianluca Castelnuovo wrote an article for Frontiers in Psychology on “Empirically Supported Treatments in Psychotherapy.” Consistent with the broader NIDA sense of evidence-based, he said the term evidence does not have one single definition. “evidence-based practice (EBP) includes many forms of evidence other than data from RTCs [randomized control trials].” There are two contradictory visions of what causes change in psychotherapy. One approach emphasizes the primacy of therapist and technique. The second vision focuses of the patient-therapist relationship and what the client brings to the therapeutic relationship.

The first vision sees the specific methods used by the psychotherapist as accounting for, by far, most of the changes in therapy. “Other factors (e.g., therapist relational qualities, patient–therapist relationship) are secondary, at best. This viewpoint is seen most notably in what have been termed the EST and EBP movements.” This approach conducts tightly controlled outcome studies, where specific treatments are pitted against one another or a control group and applied to specific disorders, usually as defined in the DSM. This describes the Project MATCH study, for which TSF was developed. This first sense proceeds from a medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.”

The second view of psychotherapeutic change attributes most positive therapeutic outcomes to client factors (40%) and the therapeutic relationship between client and therapist (30%). The technique used and the skill of the therapist accounts for 30% of positive therapeutic outcomes. This so-called “common factors approach” then discourages attempts to pit one therapy against another or against a placebo group of no treatment (clients placed on a waiting list) as ultimately doomed to failure, since all therapies have the same potential for positive outcomes (the dodo bird effect). And the relationship between the therapist and client is the most important factor for change. Here is where the fellowship sense of A.A. fits because what makes it work is the community of fellow sufferers helping one another.

When discussing the significance of common factors in “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Barry Duncan noted how experienced therapists know psychotherapy requires the unique tailoring of a therapeutic approach to a particular client and circumstance. And if a therapist attempts to do therapy by the book, it often doesn’t go very well. There are limitations to manualized therapies, even TSF.

The structure minimizes the factors brought to therapy by the client. It restricts or eliminates the therapeutic relationship or fellowship between client and therapist. And it emphasizes the factors (therapist and technique), which typically have the least positive outcome effects. If you want to determine whether a therapeutic approach is “evidence-based” or “more equal” than other therapies when treating a designated DSM disorder, you will likely use a structured, manual-based treatment. And you will have a wrong-footed, biased sense of relationship-based models of change like the Twelve Steps of A.A.

For more information of the therapeutic power of common factors and the dodo bird effect, see the above-linked article by Barry Duncan. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”; or “The Dodo Bird Effect” and “Another Brick in the Wall” on this website. If you are interested in exploring “the science behind 12 Step recovery,” try If You Work It, It Works! by Joseph Nowinski.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: alcoholics anonymous