Stanton Peele, Ph.D. , our guest, is a psychologist, author, lecturer and lawyer. We discussed addiction and recovery, his beliefs about why people become addicted and the addiction treatment process including the AA (Alcoholics Anonymous) 12-step approach to treatment for addictions.
David Roberts is the HealthyPlace.com moderator.
The people in blue are audience members.
David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "An Alternative View of Addiction and Recovery." Our guest is a psychologist, author, lecturer and lawyer, Stanton Peele, Ph.D. Dr. Peele has some strong and non-mainstream beliefs about addictions and the addiction treatment process.
Good evening, Dr. Peele and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Much of the mainstream medical world believes that addictions have some sort of genetic and/or biological component. You have a different viewpoint on why people become addicted to substances and destructive behaviors. I'd like to start off with having you explain that. (Extensive information on different types of addictions and addictions treatment in our Addictions Community Center.)
Dr. Peele: Even those engaged in genetic research recognize that claims commonly made on behalf of genetics -- e.g., that people inherit loss of control -- simply cannot be true. That is, the most optimistic claims are that people have some sensitivity to alcohol which influences the overall equation of addiction.
David: What, then, is your theory behind why people become addicted to certain substances and behaviors?
Dr. Peele: People utilize the effects of alcohol like they utilize other experiences: for the purposes of satisfying internal and environmental demands with which they are otherwise unable to cope.
The best example was the Vietnam experience, where soldiers took narcotics but largely desisted at home -- in other words, they used drugs as a way of adapting to an uncomfortable experience, but they rectified that in other circumstances.
David: To clarify then, what you're saying is that people become addicted to things because they can't cope with their environment any other way.
Dr. Peele: Yes, and they often shift in their reliance on drugs, alcohol, et al. depending upon shifts in their environments or as they develop the resources with which to cope.
One of the things most wrong -- and wrongheaded -- about disease theories of addiction is that they predict a one-way trip downhill. In fact, all data shows that the majority of people reverse addictions over time, even without treatment.
David: What are your thoughts about treatment for addictions?
Dr. Peele: Pretty dismal. We allow virtually only one type of treatment -- 12 step treatment -- which has been shown to be highly limited in its applicability. That is, we face this great contradiction -- people claim we have an unmatched and successful way of coping with addiction -- only, despite its popularity and imposition on so many people, we have increasing levels of addiction and alcoholism.
David: And what do you feel is wrong about the 12-step approach?
Dr. Peele: Other than this clear evidence that it has a limited positive impact on our society, I personally feel its model of human behavior is limited for most people ( especially the young) in its emphasis on powerlessness and self-sacrifice. I feel that for most people in most situations -- a belief in self and emphasis on enhanced skills and opportunity are the best keys to positive outcomes.
David: So for someone who is addicted to alcohol or cocaine, for instance, what would you suggest to them to help them overcome their addiction?
Dr. Peele: I don't think this is the best way to approach the problem -- to suggest to people what they might do.
People are struggling to improve their lives and to combat addiction all the time. I seek to help them develop the resources with which they may succeed. You know, people try to quit addictions -- like smoking -- for years. Ultimately, many succeed, and it's not because I gave them a great philosophy or treatment for addictions.
David: So are you essentially saying: "if you have an addiction problem, figure out what works best for you and do it? Eventually, you'll find the answer."
Dr. Peele: Often, this works. Of course, people seek help from me and others when they are discouraged, or we see recalcitrant individuals. In these cases, my job is like an interior explorer, to help examine their motivations, skills, opportunities, and deficiencies with them in order to develop a path out of the thicket.
Again, I am a helper -- people escape their own addictions. But I have seen how people summon their resources to do so, and I have some idea of which resources and ways of coping -- with stress, for example -- often accompany remission.
David: What about the idea that eventually, at some point in a person's life, they will outgrow their addiction?
Dr. Peele: This occurs remarkably often. In one colossal survey by the government of 45,000 people who had ever been alcohol dependent, and three quarters of whom had never sought treatment or AA (Alcoholics Anonymous), about two-thirds of the untreated were no longer dependent.
Obviously, many people do seek treatment, and of course many might not escape addiction without formal help. But when I perform such assistance, I see it as aiding the natural curative process, which is in itself so strong.
David: We have some audience questions, Dr. Peele, so let's get to those:
Biancabo1: As an addiction counselor, often I have clients who have concurrent disorders. The latest research emphasizes treating both the substance problem and the mental health issue simultaneously. Do you agree?
Dr. Peele: I can't speak as an expert to dual diagnosis problems. I can say that I see the development of coping with one's environment to be critical to both. I also know that, in all emotional-behavioral disorders, people with added difficulties, one on the other, face greater difficulties in remission. I say this not to be pessimistic, but to express sympathy for the depth of the problem. At the same time, I am not at all discouraged that these individuals will be able to improve their lives as well. One last point -- we can't set impossible goals. One other thing wrong with our treatment is our insistence that remission means being perfectly good all of the time. A more incremental approach, embodied in harm reduction, will benefit more human beings.
David: Do you feel that a person with an addiction needs some sort of therapy, even if it's not a 12-step approach, to learn how to better cope with his/her environment?
Dr. Peele: No, not at all. What about the 45 million Americans who quit smoking? I do think that facilitative environments -- involving human support of one form or another, among other things, enable more people to succeed, but formal therapy is not a necessity.
Xgrouper: I still have a lot of anger about treatment. If I had known the first time, I would have never gone in due to the nature of the 12 step treatment they used. I went back a second time under pressure from my work and family but was miserable. If they would have told me upfront that there was a religious aspect to that program, I never would have gone in. I do not trust the recovery movement one little bit. I have a lot of anger towards addictions treatment centers and the 12 step community. What are your thoughts?
Dr. Peele: Well, now you are in my pipeline (I just published a book, "Resisting 12-Step Coercion.") There is no excuse for the amount of coercion in our system and the almost total absence of what is recognized as the necessity of informed consent in other areas of therapy.
Why are people so afraid to outline and accept alternative approaches, and to allow people to sample or try different approaches? So much of success is due to the conformance of the approach to the person's values and beliefs, this would indubitably improve outcomes.
David: Is there any value then, in your opinion, in "spirituality" in a person's recovery?
Dr. Peele: Spirituality as a requirement, among other things, violates American religious freedom. Of course, if a person is oriented that way -- just as if religion is a strong force in their life -- then this may be a valuable resource. I also believe in the value of having goals that go beyond one's own individual concerns. I come from a very community-oriented and political background.
The task becomes to seek out which values are most motivating and supportive to the particular individual. I often speak of my uncle Oscar, whose opposition to GE and capitalism caused him to quit smoking -- so he wouldn't be a sucker to the tobacco companies, but that doesn't "prove" that communism is the cure for cigarette addiction.
David: Here's the next question:
Annie1973: My husband has been fighting an addiction (crack cocaine, to be specific) for years now and is slowly getting better. His problem seems to be aggravated by success. He is a very intelligent, talented man. He has just learned of an upcoming promotion, and due to his past behavior, we are both a little worried this will bring on a relapse. Is there anything I can do or suggest to him to get through this without fail?
Dr. Peele: Forewarned is forearmed. An important ingredient in relapse prevention is:
(a) anticipating rough spots where relapse is likely; and
(b) imagining these moments and planning alternatives and resources to avoid relapse.
I would, as a therapist, ask your husband to imagine just when and why he will relapse, understand those dynamics, and then do a hell of a lot of planning for alternative outcomes at those key moments of challenge.
David: What are your thoughts about using medications, like Antabuse, to treat substance abuse?
Dr. Peele: I have lately become somewhat involved with some specialists, like Joe Volpicelli, (read Medical Treatment of Alcoholism Online Conference Transcript with Joe Volpicelli) who rely on naltrexone, which has shown some success. However, I would never rely on a medication by itself, or even primarily. I see it (like antidepressants) as clearing the space for building a substantial basis for sobriety. You need to be alert to plan, develop resources, create a supportive environment. But once engaged in these activities, I see them as being the substance and structure of improvement and non-addiction.
freakboy: I am not a religious person in any way, but find the 12 steps program very helpful. Are you familiar with the term "dry drunk," meaning to abstain but not necessarily being a happy person, or recovered, for that matter. Without some amount, some level of spirituality, one might just be living a false recovery. How do you deal with this type of issue in your approach?
Dr. Peele: Dry drunk seems to me to be a pejorative term employed at will by 12-step supporters. For example, I have seen it used when people quit without AA (Alcoholics Anonymous), or quit AA. Alternately, it can be used to excuse flimsy outcomes within AA. In other words, a person struggles to quit drinking but fails to attend to substantial life issues. This, for me, is a testimony to the limitations of AA.
But AA members can use this obvious -- if not failure, then at least less than fully adequate outcome -- as a way almost to justify their failure. They say, "he just didn't fully get it." I find this kind of recrimination against people who do not take well to, or succeed at the 12 steps, to be commonplace. In my approach, I follow people's leads. I take what they say is important to them and work in terms of that, not by imposing my views, values, and judgments on them.
David: The 12-step approach is: an addict is an addict for life. If you stop ingesting the substance, you can't ever have it again or you will become addicted again. Do you believe that's true?
Dr. Peele: No. This kind of thinking is, in most cases, harmful and self-defeating. Not that there are not many people who should not avoid certain behaviors, certainly in the near-term. But virtually all alcoholics drink again -- the question is only how they view that drinking, how they cope with it, and where they proceed from taking that next drink.
David: So you're saying, "if you can handle it, fine. If not, then don't do it." Am I correct?
Dr. Peele: Not exactly, but good try. I say, "How are you going to make progress over the way you may previously have handled it." Remember, at any given moment, a microscopic number of people are quitting any addiction entirely. For the rest, we start at the worst outcomes -- how are you going to avoid killing yourself or others (as Audrey Kishline did)? This may involve turning your keys over to others, drinking in your basement, etc. I then turn towards the goal or minimizing all-out relapse, by getting people to cut off their binges, or returning to their goal of abstinence --meanwhile increasing the time between negative outcomes and the severity of these outcomes. In this larger picture, some people will quit altogether, and some will actually succeed at being controlled users, but if we limited our successes to just these people, we could not justify virtually any therapeutic effort.
You know, the government (through the NIAAA) just spent the largest amount of money ever on a clinical trial of psychotherapy. This was project MATCH, where 12-step, coping skill, and motivation enhancement therapists developed manuals, supervised training, and scrutinized therapy with a selected group of skilled therapists.
The ultimate result was declared a success by Enoch Gordis, director of the NIAAA. However, in order to do so, he was forced to rely on the fact that, overall, these alcoholics reduced their drinking from 25 to six days a month, and from 15 to 3 drinks per occasion of drinking. Gordis hates controlled drinking and often puts it down, but with this large, alcoholic population, improvement is the only way to see any progress -- the amount of absolute abstinence is bound to be minimal and discouraging.
sheka2000: What happened to admitting you have a problem, taking responsibility for that problem, and working on that problem.
Dr. Peele: I'm for that. But there are actually therapeutic techniques for assisting that process, called motivational enhancement. In brief, this involves exploring the individual's values, calling attention to conflicts between what that person him or herself considers important and their behavior, and then assisting them to channel this unpleasant realization in the direction of ameliorating the problem behaviors in which they are engaged.
sheka2000: That still comes from personal admission to a shortcoming, correct?
Dr. Peele: No, I wouldn't call it a shortcoming. I would call it a deficiency in the realization of one's goals and values. Perhaps this sounds like semantics, but I don't find people do best when others emphasize their weaknesses. Have you ever watched a daytime talk show where they bring in children who are acting out and then assign them to boot camp instructors who shout at and demean the kids? I don't believe people are best ready to change when they are assaulted like that. Rather, they do best when they feel the best about themselves.
joslynnn: In my experience, there is no sanity and no control once an addiction is in action. Do you consider this an extreme case?
Dr. Peele: Yes, and even in the most extreme cases -- of insanity as well as addiction--people frequently have moments of cogency and control. I think much is justified by claiming people have no control or ability to be aware of themselves. But this is rarely the case with most people, and never the case all the time with even the worst addicts.
scottdav: Would quitting of alcohol altogether, without some kind of taper in the amount being drunk beforehand, not be dangerous since the body has developed a physical need for the alcohol?
Dr. Peele: If you are looking for reasons why people might want to abstain, there are many. However, when someone has been drinking for years and decades, the idea that all of a sudden they must totally abstain seems alarmist, even when they are doing themselves considerable harm. Rather, we can avoid panic and try different approaches when we can realize that we cannot gain in several weeks what a person has failed to demonstrate for many years or several decades. Nonetheless, it may well be best for this person to aim for abstinence, or virtual abstinence, for their best health outcomes. But let me also remind you that, believe it or not, overall drinkers outlive abstainers. Of course, there are some drinkers who bring that average way down. But, and here is the strange contradictoriness of human existence, abstinence is a mortality risk factor.
David: Here are a few audience comments on what's been said tonight, then we'll take a few more questions:
Biancabo1: I have been involved in counseling people with substance abuse problems for the past 7 years, and I still find the most difficult aspect is letting go and trusting in the process, especially as it applies to the family members.
Xgrouper: Thanks for being here tonight. I am a big fan and visit your website for accurate and up-to-date information on today's issues. Keep it up, you are doing great things.
sheka2000: The 12-step approach has saved many lives, and created direction for many. My thought is if it works, why fix it? As a recovering addict, I gotta say that I disagree that there are moments of cognitive choices in the midst of addiction.
David: Here's the next question:
Steve1: Why is alcohol such an issue? So many other drugs are thrown at us to help us, but if you drink a beer--it's bad?
Dr. Peele: You may be a little different in your experience from most participants at this site. They are people involved, either personally or professionally, with alcoholic excess. Given that, we do not minimize the damage that many people suffer from alcohol. I did just say that much drinking is not only not harmful, but, ironically, has substantial benefits. I just published a massive research paper (in the current issue of Drug and Alcohol Dependence) finding that in a number of key areas of psychological functioning, including mental health and cognitive acuity, moderate drinkers are in better shape than abstainers, even lifelong abstainers (that is, not people who quit drinking).
scottdav: Would it not be more likely that the person would achieve better results by breaking down, giving up alcohol in steps, rather than aiming for the goal of giving up completely?
Dr. Peele: Often, yes, but not always, and it is hard to dictate that sort of thing. Of course, I might ask you, do you think most people do best by quitting smoking altogether, or by trying to cut down. The conventional wisdom is quitting altogether is necessary. I think this is overstated, even with tobacco, but it certainly seems to be pertinent for many people.
David: I know it's getting late. Thank you, Dr. Peele, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people in the chatrooms and interacting with various sites.
Please feel free to stay and chat in any of the other rooms on the site. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com/. Thank you again, Dr. Peele, for being our guest tonight.
Dr. Peele: I welcome and appreciate this opportunity. People seemed to feel free to speak with a range of viewpoints. I hope they benefited from my views, and I know I enjoyed and benefited from theirs. Please do not hesitate to call on me again.
David: Good night, everyone.
Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.
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Conversely, individuals with substance abuse disorders often have co-occurring psychiatric disorders. But are the substance abuse problems of patients with major mental illnesses less severe than those of patients in substance abuse treatment? Are the psychiatric disorders of patients receiving substance abuse treatment less severe than those of psychiatric patients? Scientists at the University of California-San Francisco conducted a study that addressed these questions. They compared, at treatment entry, 120 substance abuse patients who had co-occurring psychiatric disorders with 106 psychiatric patients who had co-occurring substance abuse disorders. Both patient groups were in public, acute-crisis, residential treatment programs, within either the mental health or substance abuse treatment systems.
Dr. Volpicelli: 
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