Jails, Institutions, and Death, pt. II
by Thaddeus Camlin, Psy.D.
Earlier this year I wrote a piece arguing that 12-step programs are wrong when they claim that drug use invariably leads to jails, institutions, or death. The piece generated a decent amount of dissenting responses (even more than most of the stuff I write!). Impassioned retorts proclaimed that I built a “straw man” argument by referring to drug use leading to jails, institutions, and death, and insisted that the 12-step programs only make the ominous claim about people in “active addiction.” Inherent in the dissenting opinions is an implied agreement that the original article was correct in claiming that most substance use does not lead to jails, institutions, and death, so at least we agree on something. Now, let us narrow the focus from the fact that most drug use does not lead to jails, institutions, or death, and in the hopes of constructing a steel man argument focus solely on the idea that someone in “active addiction” will inevitably find themselves imprisoned, in rehab, or dead.
First, it will be helpful to clarify what is meant by a vague term like “active addiction.” The DSM5 removed addiction from its diagnostic terminology because of its “uncertain definition and its potentially negative connotation” (p.485). The Surgeon General’s report on addiction in 2016 argued that terms like addiction and alcoholism should be considered to refer only to people with a severe substance use disorder, not the mild and moderate forms of disordered use. Hopefully most of us can agree that the term ‘active addiction’ refers only to people experiencing severe problems as a result of an addictive behavior.
The beleaguered bromide about jails, institutions, and death is referred to across much of the 12-step literature. One Narcotics Anonymous message to newcomers claims that “our ends are always the same: jails, institutions, or death.” Yikes! Not much to hope for there. In a popular piece of AA literature, the book 12 Steps, 12 Traditions, one passage reads: “Each AA member is to follow the 12 steps to the best of their ability or face jails, institutions, or death.” In this case, being totally abstinent is not enough to avoid dire outcomes, one must also follow the 12-steps to the best of one’s ability in order to avoid jail cells and caskets. I would hope that few people find cause to repudiate the notion that following the 12 steps to the best of one’s ability is not the only hope avoid death and jail. Multiple pathways to successful recovery is so well-established now that it is essentially an afterthought, a ‘duh, no-brainer.’
People in AA and NA regularly experience a full-blown relapse, then get back to meetings and get back on track without going to jail or rehab. The DSM5 could not be more clear, stating that disordered alcohol use is “erroneously perceived as an intractable condition” and that most people with alcohol use disorder have “a much more promising prognosis” (p. 493) than jails, institutions, and death. The mentality that one drink is too many and a thousand is never enough, and that deviating from the 12-step program will inevitably lead to institutions and death (remember, “our ends are always the same”) is not only not true, it contributes to the abstinence violation effect. The abstinence violation effect occurs when a single breach of abstinence justifies a complete return to an old pattern of use. If people think one drink will take them to jail, rehab, or the morgue, such thinking is more likely to lead to that reality – a classic example of self-fulfilling prophecy.
The reality is that slips are common in any effort to change an established pattern of behavior, and that all-or-nothing thinking tends to hinder efforts to change. The Japanese proverb reminds us that one frost does not make a winter. Similarly, one night of drinking does not make a relapse and jails, institutions, or death are rarely the outcome of addiction. Most people recover from addiction, and most do so without ever going to a meeting or treatment. Jails, institutions, or death are the rare exceptions. In the world of addiction treatment the time is long overdue to spread hope based on scientific research rather than fear based on opinions and traditions.