Chicago Tribune John Keilman column

April 01--Close to 20 years ago, I ventured into a church basement to witness a meeting of Narcotics Anonymous. I had been invited by someone who was helping me research the drug problems of a small East Coast town, and while I no longer recall the story I wrote, I certainly remember the meeting.

Pots of black coffee simmered on hot plates and a veil of cigarette smoke hung in the air. The attendees included white-haired gentlemen with monogrammed shirts and shaggy young guys who looked like they lived on the streets. When someone spoke about how drugs or booze had wrecked his life, the rest of the room was dead silent.

Though I was just an observer, I could feel the sense of community in that basement. Everybody was respectful. Nobody was sitting in judgment. The people who shared their stories appeared to be relieved and gratified when they were done.

I have since interviewed dozens of people who have been in the grip of addiction, and almost all of them were veterans of the 12-step approach. Some swore by it, carrying a well-thumbed copy of the Alcoholics Anonymous "Big Book" wherever they went. Others were disdainful, resenting what they saw as the program's coercive and religious nature.

The 12 steps, popularized in the 1930s by AA co-founder Bill Wilson, are the foundation of drug and alcohol treatment in America, embedded in everything from homeless shelters to high-priced treatment facilities. Boiled down, the steps direct substance abusers to acknowledge their addictions and seek help through "a Power greater than ourselves."

There is no question that these methods help a lot of people -- Roger Ebert wrote movingly about how AA helped him quit drinking -- but they attract plenty of criticism, too, and last week a Los Angeles psychiatrist launched a new and compelling salvo.

In his book "The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry," Dr. Lance Dodes examines the research and concludes that only 5 to 8 percent of people who try the 12 steps achieve and maintain sobriety for longer than one year -- roughly the same result as addicts who get no treatment at all.

Yet 12-step programs continue to be held in high esteem, a reputation Dodes told me is due to "a classic sampling error: We hear from the people who do well; we don't hear from the people who don't do well."

He said many in the latter category are actually harmed by participating in the 12 steps: Because the program is often represented to be infallible, those who don't benefit can develop a sense of failure that leads to depression and even more trouble.

Dodes argues that a better approach to addiction is psychotherapy. Substance abuse is a response to feelings of helplessness, he said, and addressing those emotional symptoms in constructive ways is the key to resisting drugs and alcohol. Communal programs such as AA or NA are not designed to do that job, he said.

For an alternative opinion, I spoke to Ramsen Kasha, executive director of the Chicago branch of the Hazelden Betty Ford Foundation. Its program relies heavily on the 12-step approach, though Kasha said it uses other elements, too, including psychotherapy.

He said the 12 steps have proved their worth over decades, and while they might not work for everyone, they offer "the best chance" of guiding people toward sobriety by encouraging them to form connections with others and take responsibility for getting better.

"Those are aspects of 12-step programs that are based on the principles of honesty, hope and courage," Kasha said. "Quite frankly, they help addicts but they're not bad principles to live by for anyone."

I can understand why Dodes and others believe that the 12 steps are oversold. Plenty of substance abusers need things a meeting can't provide, including psychiatric medication, long-term therapy, a safe place to live, a good lawyer and a good job.

But the full menu of support costs money, and in an age of lean government budgets and penurious insurance companies, that money is not likely to be forthcoming. So for many people, that leaves the church basement and the Big Book.

Addiction is difficult to treat under the best conditions, so it seems to me that even a 5 to 8 percent success rate for something that's free and open to all isn't so bad. Like anything else, 12-step programs can and should be improved, maybe even replaced if something better comes along that is equally accessible. But that day appears to be far, far away.

Until then, I'm glad there are places where anyone struggling with drugs and alcohol can go, even if they gain nothing more than a few moments of acceptance. The road to sobriety can be long and crooked, and anything that helps a person take his first step ought not to be dismissed.

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