Unbroken Brain: A Revolutionary New Way of Understanding Addiction

by Maia Szalavitz

Incredibly, many programs—particularly those that receive large numbers of patients from the criminal justice system—still use this approach.

And all of this treatment rests on the mistaken idea that people with addictions must be broken and made to hit...

Tough love for families has part of its origins in Al-Anon, the program originally designed for spouses of alcoholics, which was founded by Bill Wilson’s wife, Lois. Parents and spouses here are exhorted to stop “enabling” their loved ones’ addictions in order to help them recognize their powerlessness.

As with AA, however, Tough Love was never tested before it was widely accepted and implemented. While there are clear indications that it can sometimes do harm, no one knows how widespread the problem is because there is virtually no research on what happens to people whose parents or spouses decide to practice it.

While there certainly are times when parents and loved ones need to distance themselves from addicted children for their own sanity or to protect other children, there is no way to predict whether this will harm or help the addict.

A further outgrowth of the forcing “bottom” idea is the “intervention,” which is the basis for the popular reality TV show of the same name. Again, the idea is to confront the addicted person—typically in a big meeting that can even include their boss—and threaten to cut off all emotional and financial support if he or she doesn’t comply with recommended treatment. During the meeting, participants often harshly attack the addict, trying to “break through” to them and create a bottom. Again, this has a serious potential to backfire: there have been suicides immediately after interventions, most notoriously that of beloved ’90s musical icon Kurt Cobain. (And since there are methods of intervening gently and respectfully that don’t carry these risks, the approach is particularly misguided.)

a feeling of total powerlessness and helplessness is fundamental in determining whether a horrific experience will cause PTSD, which is not exactly a sign of what is likely to promote health. Indeed, PTSD actually increases relapse risk in addicts—and having PTSD doubles to quadruples the risk of becoming addicted in the first place.

Moreover, a thorough review of the data on humiliation, punishment, and confrontation as treatment for addiction shows that it is not helpful, leading to worsening addictions and greater numbers of treatment dropouts.

Over four decades of research, in fact, not a single study has supported the confrontational approach as superior to kinder and less potentially harmful treatments, according to a review of the data by William Miller and William White. Yet both our treatment...

I read an article in the New York Times Magazine that terrified me. It was a positive profile of a New Jersey program called KIDS, an unapologetically harsh youth rehab. Treatment at KIDS consisted primarily of sitting rigidly in one particular position on hard chairs for 12-hour days and being subjected to constant emotional attacks. I would later write a book that exposed just how torturous and harmful that particular program was. I learned, for instance, that one thirteen-year-old girl, who didn’t even have a real addiction, was held in it for thirteen years, eventually winning a $6.5 million settlement in a stunning civil case that exposed emotional, physical, and sexual abuse.

Unfortunately, by taking a one-size-fits-all approach and assuming that all people with addictions have the “defects of character” that the 12-step programs associate with “the disease,” this model tends to undercut itself and undermine its ability to teach. By presuming that all addicts have antisocial personalities, the Minnesota Model can also bolster and promote ineffective ways of teaching and counseling.

What happens in many rehabs is still more like indoctrination than education. By telling patients to “take the cotton out of your ears and put it in your mouth” and seeing even sincere questioning as defiance, the programs diminish their own ability to educate and motivate change.

Learners do not respond well to patronizing teaching that dismisses or punishes questions. And when every patient is seen first as a liar, a manipulator, a criminal, or worse, rehabs do not create an environment conducive to the curiosity and openness that inspires learning.

Indeed, the research shows that they are counterproductive. One study found that the more a counselor confronts alcoholic patients, the more they drink. Other research shows that it is not whether a counselor is herself in recovery that matters for success, but instead, how kind and empathetic she is—or isn’t.

* ADDICTION WAS INITIALLY characterized as a type of antisocial or psychopathic personality disorder. It is easy to get this misconception when antisocial behavior is defined largely by lawbreaking, and drugs are illegal.

the first research on addiction was typically done inside of prisons. But obviously, this is likely to produce a skewed picture of those with drug problems.

It is neither necessary nor sufficient to be cruel, selfish, or dishonest to meet addiction criteria.

One of the most important implications of understanding addiction as a learning disorder is recognizing how different temperamental predispositions can lead people to develop it and distinguishing between them in order to treat people compassionately and effectively.

research suggests that creating a coherent narrative out of your experience may help recovery from trauma,

IN 1935, WHEN Bill Wilson and Robert “Dr. Bob” Smith created AA, both were members of a then-popular Christian revival movement known as the Oxford Group. The steps were based on the Oxford Group’s principles of surrender to God, confession, restitution for harms done, prayer, and service to others through proselytizing. But AA soon split off from the Oxford Group, which had been founded by a controversial preacher named Frank Buchman.

(Just before the split, Buchman did not help his reputation when he praised Hitler and sought to convert the Nazi leadership into becoming his followers.)

In the program, I learned that if I could just stop hating myself for hating myself, I didn’t feel quite so bad.

While the steps didn’t formally address the issue, in meetings I’d hear people talk about swinging from grandiosity to self-loathing, often described in AA’s earthy language as “feeling like the piece of shit in the center of the universe” or being “an egomaniac with an inferiority complex.”

“don’t compare your insides to someone el...

I began to learn the critical recovery skill of self-compassion.

Part of what the program gave me was hope—what AA calls the “power of example.” Seeing people similar to me get better made a real difference—and I still think that this is often a crucial element in recovery.

the supportive community that 12-step programs provide is the main active ingredient in their success, when they work.

We all tend to learn best when we feel safe and curious and want to connect and win our teachers’ respect.

in a meeting full of strangers or semistrangers, the need for positive self-display is less pressing. For me, listening to a well-known model discuss how ugly she thought she was or hearing a renowned journalist discuss how he saw himself as a failure came with the hopeful suggestion that there was some possibility that my own negative ideas might be similarly deluded. And just hearing others admit their anxieties, fears, and hopes inevitably helps ground you.

the same clichés that originally put me off sometimes held important truths. The rhyme “put gratitude in your attitude” still sets my teeth on edge. However, I recognized that I did genuinely have a tremendous amount to be thankful for and that focusing on this, in part simply by taking up mental energy, could push out negative thoughts and make me feel better.

In the same way, the cheesy sign that said HALT, which stands for “Don’t get too Hungry, Angry, Lonely, or Tired,” gave me clues about what physical and emotional needs to take care of when I seemed to want drugs out of the blue. Sure enough, I’d often discover that a “drug craving” was actually hunger, irritation, or a...

I later realized that the 12-step slogans are basically the groups’ collective wisdom about how to deal with stress, anxiety, and oth...

In fact, many of the same ideas found in these often corny and haphazardly introduced sayings are the backbone of cognitive beha...

if you go to enough meetings and get a sponsor, you are likely to learn much of what CBT recommends eventually.

The program encouraged us to see the world as intimately shaped by a God who wants us to recover—and since I so urgently wanted to get better, I accepted it.

To make matters worse, I had exacerbated the problem by being hard on myself for being hard on myself, creating a recursive loop of metadistress.

By engaging in the 12-step process, I learned a new and more adaptive way of seeing myself and the world.

From the problems I’ve seen in 12-step-based treatment, I think spirituality and medicine need to be kept separate, and that the current addiction treatment system needs to be completely overhauled. But I also believe that 12-step programs don’t get everything wrong. They have simply been misused and asked to take a role that they should never have played in professional care.

Although addicted people are neither uniquely spiritually needy nor especially prone to sin, social support, meaning, and purpose do matter for recovery. And, we can reconcile the conflict between morality and medicine without making addiction an officially stigmatized “special case” and the only condition for which mainstream medical care involves prayer and confession.

The trick is disconnecting self-help from professional treatment and recognizing the streng...

Our health system isn’t well designed to cope with learning disorders like addictions or conditions like type 2 diabetes, where new types of b...

Self-help can be part of the solution in these cases, but it’s important not to sell this as medicine, nor to rely on amateurs as experts or promote any one group or ...

Indeed, the reality is that anecdotes alone simply cannot provide proof of efficacy. Data-driven approaches, like randomized controlled trials, are what give modern medicine its edge over priests and shamans.

The reason that we can now prevent or manage killers like polio or AIDS is that the scientific method allows researchers to determine what causes them and then test and rapidly discard ineffective approaches. Anecdotes, in contrast, can make quack treatments seem effective and thereby deter progress for years, even centuries.

AA is not the only way, nor is the only alternative “jails, institutions, or death,” as the slogan has it.

AA and treatments like Twelve Step Facilitation are not the only effective approaches. They aren’t even superior to other treatments when compared directly.

A 2006 Cochrane Review—the highest level of medical evidence, often used by countries with national health plans to determine what treatments should be covered—summarized the data plainly: “No experimental studies unequivocally demonstrated the effecti...

Moreover, the research that does show AA to be effective is overwhelmingly flawed by what is known as “selection bias.” Basically, this means that it looks better than it is because the people who...

In fact, when you force people into AA, they do no better—and sometimes do worse—than when given alternatives or no treatment, ac...

One study, for example, included over 200 workers mandated by their employers to get help who were randomized to AA, hospital-based treatment, or a choice of treatment. The AA-mandated group fared worst, with 63% later requiring additional treatment, c...