Toward the end of 2018, the New York Times published a lengthy obituary with the headline: “Herbert Fingarette, Contrarian Philosopher on Alcoholism, Dies at 97.” By labeling Fingarette as a mere contrarian philosopher and by otherwise subtly demeaning him, the NYT cozied up to the $35 billion per year addiction-treatment industry. The reality is that Fingarette exposed unscientific notions about alcoholism and standard disease-model treatment, and his conclusions have been repeatedly confirmed in the scientific literature.
In a deeper sense, Fingarette pointed out the damage done by authoritarian one-size-fits-all standardized treatment. There is a long list of famous rehab failures, and there are many more non-famous substance abusers who have not been helped by the standard disease-model treatment and 12-Step approach of Alcoholics Anonymous (AA). Fingarette’s Heavy Drinking: The Myth of Alcoholism as a Disease (1988) provided a refreshing alternative.
Many problem drinkers are already self-loathing because of the effects of their alcohol abuse on themselves and others, but after discovering Heavy Drinking, they did not compound this misery with “treatment failure” self-condemnations. Examining standard disease-model/AA treatment effectiveness, Fingarette pointed out: “The very label treatment . . . seems a deceptive misnomer. . . . Indeed, it has not been clearly demonstrated that such programs add anything at all to the improvement that could be expected in the natural course of affairs without a drinker’s having received any professional help whatsoever.” Yet, as Forbes reported in 2015, “The vast majority of addiction treatment is based either partially or entirely on the 12 Steps of Alcoholics Anonymous (AA).”
Labeling Fingarette as merely a contrarian is highly misleading. Several years prior to the publication of Heavy Drinking, the scientific ineffectiveness of standard disease-model treatment had been known. Harvard psychiatrist George Vaillant, in his 1983 book The Natural History of Alcoholism, had already—reluctantly—come to the conclusion that the standard disease-model/AA treatment approach used at his own clinic was, as Vaillant put it, “no better than the natural history of the disease.”
Vaillant reported: “Fueled by our enthusiasm, I and the director . . . tried to prove our [treatment] efficiency. Our clinic followed up our first 100. . . patients . . . . After initial discharge, only 5 patients in the clinic sample never relapsed to alcoholic drinking, and there is compelling evidence that the results of our treatment were no better than the natural history of the disease.”
In recent years, researchers have repeatedly confirmed Fingarette’s conclusions. The Clean Slate Addiction Site in “Substance Dependence Recovery Rates: With and Without Treatment” analyzed data from 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions.” This data is from a survey of substance abusers in the U.S. population as a whole, as opposed to examining only people who go through treatment programs. Analysis of this data revealed that the “majority of people with substance dependence actually quit on their own without any sort of treatment or 12-step involvement. . . . [and] that you have a better chance of ending your addiction if you are never exposed to treatment programs or 12-Step programs.” Moreover, the data reveals that “long-term success is more likely without treatment” (10 to19 years after being diagnosed with alcohol dependency, only 9.4% of the untreated group remained alcohol dependent, as compared to 27.3% remaining alcohol dependent who had received treatment).
A more recent support of Fingarette is the book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry (2014), lead-authored by Lance Dodes, M.D., former director of Harvard’s substance abuse treatment unit at McLean Hospital. Dodes reports, “Peer reviewed studies peg the success rate of AA somewhere between 5 and 10 percent. That is, about one of every fifteen people who enter these programs is able to become and stay sober.” Dodes examined multiple treatment studies, focusing on randomized control trials, including those analyzed in the Cochrane Review. The Cochrane Review examined eight high-quality, controlled randomized studies that included a total of 3,417 subjects, and it concluded standard disease-model treatment has not proven to be scientifically effective.
Neither Fingarette nor Dodes opposed AA, as they recognized its usefulness for those problem drinkers who become enthusiastic about it. However, mandating and coercing people into standardized AA treatment when they lack enthusiasm for it can have a negative impact. Recommending AA to all problem drinkers can be harmful, Dodes concluded, as “AA dropouts do worse than those who seek no treatment at all. . . .This makes sense, since failing to benefit from the approach that others claim to be the best (or only) effective treatment is depressing indeed.” Thus, court-mandated, employer-mandated, and other coercive treatment can do more harm than good.
In my clinical experience, Fingarette’s concept of “central activity” is of great value to people engaged in self-destructive behaviors. While for some people, religious worship or money-making can be their central activity, so too can drinking, drug dependence, or gambling become the hub of a person’s life. For some people, AA is an attractive central activity replacement to drinking; however, for many others, AA is unattractive. A more compassionate society, rather than shaming those who reject AA and standardized treatment, would provide alternative non-destructive central activities.
Absent any treatment, many heavy drinkers “mature out” of their substance abuse, creating a new hub and central activity. For instance, following marriage and children, some formerly heavy drinkers prioritize family, and this becomes their new central activity. They, Fingarette pointed out, “cultivate new values and interests . . . find or create new physical and social settings . . . develop new relationships. . . . Many heavy drinkers do this on their own initiative, ‘maturing out’ of heavy drinking with no professional help.”
While for some heavy drinkers, the labeling of their problematic behavior as a disease frees them of shame, Fingarette observed that “the disease concept does not always have this effect. Many heavy drinkers view the labels ‘diseased’ and ‘alcoholic’ as stigmatizing, and so they reject help under such terms. Furthermore, the notion that this disease causes people to lose the ability to control their drinking may discourage a heavy drinker from trying to stop in the (false) belief that it’s hopeless.”
“Heavy drinkers are a diverse lot,” Fingarette observed, “differing in individual motives and patterns of drinking.” Fingarette concluded that it would be more effective if we respected individual differences and tried to match drinkers with helper. He documented that the more a drinker and a helper have similar conceptual frameworks, and the more a drinker is comfortable with a helper, the better the chances of success.
A sad irony of AA is that, initially, its founders had great respect for the value of voluntary, non-coercive mutual aid. AA co-founder Bill W. knew that authoritarianism—demanding unquestioning obedience to a single approach or treatment—is ruinous not only for people who are pressured into compliance but can also damage the positive energy of any voluntary culture. Bill W. was attracted to the ideas around voluntary mutual aid popularized by the Russian anarchist Prince Peter Kropotkin (1842–1921) and his book Mutual Aid (1902). Bill W. pointed out, in Alcoholics Anonymous Comes of Age (1957), how attractive the anarchistic non-coercive nature and freedom of AA can be for newcomers, “We cannot be compelled to do anything. In that sense this society is a benign anarchy. . . . I think that the gentle Russian prince who so strongly advocated the idea felt that if men were granted absolute liberty and were compelled to obey no one in person, they would then voluntarily associate themselves in a common interest. Alcoholics Anonymous is an association of the benign sort the prince envisioned.”
The beauty of a truly mutual-aid group is that while individuals may join for a specific goal—in AA, to stop drinking—the non-coercive nature of a mutual-aid group can be so satisfying that it becomes a vehicle to build community, including career contacts and friends. It can become an attractive central life activity. However, overt and covert coercions routinely result in the loss of attractiveness for any individual, group, or institution. When court systems coerce people to attend AA meetings, the non-coercive culture is destroyed; and when rehab programs use AA groups as part of their money-making enterprise, this also subverts what many people find so attractive about mutual-aid communities.
In a pathetic attempt to discredit Fingarette, the NYT obit states: “Professor Fingarette acknowledged that he had not conducted any experimental or clinical studies into alcoholism; he reached his conclusions by analyzing scientific literature, he said.” Here, the NYT neglects the reality that it is common for scientists, journalists, and attorneys who themselves have not conducted any experiments or studies to analyze the scientific literature; for example, attorney Ralph Nader did not conduct safety studies on automobiles but analyzed the data for his Unsafe at Any Speed: The Designed-In Dangers of the American Automobile (1965), which is today listed by the Library of Congress as one of the 88 books that “shaped America.”
With its slick shots at Fingarette and by ignoring what is most significant about him—that he has been repeatedly proven to be correct about the scientific failure of standard treatment for alcoholism—the NYT obit pleased the $35 billion per year addiction-treatment industry.