This post is part of a series on my brother’s upcoming book Addiction Nation: What the Opioid Crisis Reveals about Us, discussing some of the science and stats he used throughout the books. Read the intro post here, part 1 here, or (best of all) pre-order the book on Amazon here.

Okay, so this week’s post is kind of a big topic. I think it’s fair to say that most of your book is actually about “what hurts and what helps” addiction, so this post is really just to talk about two of the interesting studies you used in the course of all of those chapters. I included one that had a pretty surprising conclusion and two that I know we discussed at length and you ended up doing some rewrites on. Does that sound good?

Tim: Perfect! And this is probably a good time to point out that this book probably took twice as long to write because of you. There are sometimes that authors have a point they want to make and so they start searching around until they can find a study that seems to back up the point they want to make. 

Instead, I really wanted to take the time to understand multiple different models and viewpoints for understanding addiction. That meant spending a lot of time with opposing viewpoints. And, when I found a study that I thought was interesting or exciting, I had the specter of my older sister looking over my shoulder reminding me to go back to the source material. 

Unfortunately, there are a lot of people out there who don’t have sisters who wouldn’t mind calling them out publicly for being sloppy with their research. In Chapter 9, I highlight the destructive game of scientific telephone that turned a small letter to the editor in the New England Journal of Medicine into a “landmark study” that Purdue Pharma used to claim that fear of opioid addiction was overblown. 

If only they all had sister’s to give them a healthy dose of neuroticism…

Note to authors: if you’re lacking a sister to keep you honest, I’m available for hire!

Alright first up, the study that was surprising. I would love to take credit for how you introduced this study, but I actually have to admit you did this phrasing all on your own. For some context, this is on page 35 after you talk about how hearing your doctor say that your addiction wasn’t your fault was so valuable to your own recovery. You say a few things about the disease model of addiction, then you say this:

But the disease model isn’t the only way to understand addiction. In fact, there are limitations. At least one study shows that alcoholics who believe their alcoholism is a disease are more likely to relapse than those who don’t.

That was some great context. So many people get concerned with making a strong statement that they forget/ignore counter evidence. At the same time, noting that it was “one study” helps give the reader some useful context about how widely this has been found. Nice job brother!

Tim: This was a big area of learning for me. When I first started learning more about addiction  I thought of there being two opposing camps. The first represented the old outdated model of addiction as a moral failing. Then there was the new wave of scientific research that showed addiction is a disease. 

While the disease model dominates addiction science, I started to read a lot of great authors and researchers who either explicitly argued against that theory or were offering important correctives to it. These folks include Bruce Alexander, Marc Lewis, Carl Hart, William Miller and Maia Szalavitz (who you first introduced me to.) While I don’t always frame what I write as a critique of the disease model, there is a lot that comes from authors and researchers who are doing exactly that. 

A scientific model is a framework that is used to understand a complex phenomenon. Models can have benefits and limitations. In theological language, you can talk about an “icon”. It is an image that points to or is analogous to a reality that transcends it. An “idol” is when you believe that what you are looking is the greater truth itself. 

The study you mention is this one here “What predicts relapse? Prospective testing of
antecedent models“. It was done on 122 alcoholics who entered recovery, then were assessed for a bunch of different things pre-treatment and then every 2 months through a year to see what types of things correlated with relapsing. Here’s the finding you mention:

I highlighted the Bonferroni adjustment part because I think that’s an important note for how rigorous this study was. The authors did a ton of comparisons/correlations to see what factors might be relevant. They highlighted both those that came up as significant (and thus might be worth exploring) but also noted that due to how many correlations they were running they really should have used a higher cutoff. This is a great way of doing initial data analysis on a topic like this and shows they were really interested in getting to the truth. So basically the disease model issue had some initial evidence but needed more study to be proven.

They then pulled all the data to look at just this factor and showed that the disease model belief was associated with relapse at every time point. This gives even more statistical weight to the theory. They also give this caveat:

The direction of causality cannot be determined from these data. It is possible that belief in alcoholism as a loss- of-control disease predisposes clients to relapse, or that repeated relapses reinforce clients’ beliefs in the disease model. In any event, endorsement of traditional disease model precepts was prospectively predictive of relapse.

That seems like a reasonable conclusion, and certainly intriguing. Not sure what we really do with that information though, other than work it in the way you did. Any thoughts?

Tim: I think this speaks to the power of language in our lives. When we, as a society, understand the ways that addiction is like a disease, we are motivated to look at the social, economic and medical factors at play. It motivates all of us to look at the public health possibilities that can make a difference like increasing access to treatment in general, MAT (medically assisted treatment), harm reduction and other social supports. 

However, it is also reasonable to assume that some people might use the language of disease and assume that puts the responsibility for recovery solely on outside factors. JD Vance, in Hillbilly Elegy, describes his own interpersonal frustration with his mother who used disease language to justify her abusive behavior toward her children. 

Maia Szalavitz, in the book you recommended to me, uses the language of addiction as a learning disorder. Recovery isn’t a simple “choice” in the way we normally use the word. But that doesn’t mean there aren’t tactics and strategies a person can learn that help them overcome and compensate for the harm addiction can cause.

Final thought on this one is that addiction comes in lots of different shapes and sizes. One direction I hope addiction research goes is not just asking, does this work for a general population? But, are there specific kinds of addictions and backgrounds that make specific approaches, language, and treatment more effective?

For example, Bill Wilson was a relatively wealthy banker who should have “had it made” but lost everything for a while because of his alcoholism. There is a whole category of people, like him, who might need to start with addiction as a disease and learning their own powerlessness. 

But what about those who had an addiction with roots in an abusive childhood in which they always experienced themselves as powerless and their world as out of control? Maybe the place they would need to start is with their own agency. 

That’s a good point. We often think of treatment as “working for people” or “not working for people”, but the effect may not be consistent across all populations. This actually an excellent intro to the next study I wanted to talk about….

There were two studies that we probably discussed more than almost any others: “The forest and the trees: relational and specific factors in addiction treatment” and “Effect of Counselor Expectations on Alcoholic Recovery“. I objected to your initial framing of the findings in these, and you ended up changing how you presented them. In these two studies, it was found that counselor empathy and counselor’s belief that the client was going to succeed impacted the outcomes for the addict. In the first study, they showed that treatment approach mattered less than the counselors “accurate empathy” level, and the second found that when counselors were told the addict was likely to succeed (on a scale that was actually randomly assigned) they did better.

Now normally this point is just made as a sort of “counselors, be better” without any further nuance. When I dug in to the papers though, I got concerned that there was a pretty big caveat. In another paper that reviewed the findings of the previous two papers (Rediscovering Fire: Small Interventions, Large Effects) the authors point out that this effect didn’t come from changing the behavior of some or even most counselors. Instead, they said:

Therapists’ experimentally induced expectancies about their clients
become self-fulfilling prophecies in treatment outcomes (Leake & King, 1977), and patient retention rates are predictable even from the tone of voice a doctor uses when talking about alcoholics (Milmoe, Rosenthal, Blane, Chafetz, & Wolf, 1967). At least two studies suggest that therapist effects may reflect the impact of a relatively small number of counselors whose clients show particularly poor outcomes (McLellan, Woody, Luborsky, & Goehl, 1988; Project MATCH Research Group, 1998). In our first study of therapist effects (Miller et al., 1980), clients seen by counselors low in empathy fared worse than those given brief intervention and sent home with self-help materials.

So basically it’s not your average counselor who needs to change, it’s actually your burnt out or otherwise low performing ones who may need to be addressed. You added this caveat to both your citations (Chapters 19 and 21), and I think it’s a stronger point for it. It’s amazing how often these two things get cited without the nuance, so I’m kinda proud you got it in there. How did you feel about it?

Tim: Annoyed. I had to go back and rewrite stuff because of you and your pesky attention to detail and facts. 

This is an area where at first I was worried that the study would somehow lose rhetorical power but the caveat, but it actually deepens the point. The important change isn’t large scale training to get a counselor from an 8 to a 9 on the empathy scale. It is a broader scale distinction between someone who is clearly burned out and has stopped caring with those who are generally empathetic and trying. This specificity in the research actually led me to want to make two broader points more strongly. 

First, I write a lot about empathy and understanding for those who struggle with addiction. This study points to the need to support those who work every day with those who struggle with addiction. First responders, medical staff, social workers and so many others on the front line are getting burned out. We need to make sure they are supported. The work they are doing isn’t easy. 

Second, while I’m going well beyond the bounds of the study now, I think it illustrates the importance of societal attitudes toward addiction. If struggling with addiction continues to be a “Scarlett A” that marks a person for life, then we create a world in which that addiction is more likely to stay with a person for life. If our fundamental assumption is that redemption and growth is always possible and that struggle and setback is not a curse of the few but a description of what it means to be human, then we are creating a world where recovery is more likely to be a reality. 

I’m glad you ended up feeling that way about it. I think that with many scientific findings, the nuanced truth is often more interesting than the initial simple point you were going for. Life is messy, so is the data, as I always say. (Actually I think I made that up just now, but I like it and it may be my new thing.)

Alright, I think we’re done here! Next week we have even more debating to do, as we’re going to cover two studies that actually have produced a lot of debate in the popular press. Hope you’ll join us!