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Comment by KingMob | Hacker News Reader

> The 12-step view is that there isn’t a “once and done” cure. If I were to use an analogy it’s more like having lifelong diabetes. You gotta keep taking that insulin. It’s the continuity that forestalls the disease/ keeps you in remission.

This is actually one of the things that many psychologists are dubious about. It's entirely possible that self-labeling as an alcoholic forever makes it harder, not easier, for some people to remain abstinent.

To the extent that it keeps you vigilant and involved in a supportive community, it can be good. But it could also make it harder to get back on the wagon if you have a single drink if you think you're "an alcoholic", and not "a sober person who made a mistake".

Due to the anonymous and heterogeneous nature of AA, good data and studies of its efficacy are very hard to come by, so we have little idea if it's actually better than non-AA or pharmaceutical alternatives.

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Identifying as an alcoholic or gambling addict or drug addict etc, is no different than saying "I'm a diabetic". It's the label of a chronic disease. Applying that label to self is about acceptance of that as a fact of life that you can then work with. If you've ever been unfortunate enough to see e.g. a diabetic who did not accept the reality of their illness - it's not pretty. Acceptance is the price of vigilance.

I also believe you've misunderstood how we view ourselves (and each other) when we fall of the wagon/bust/slip. I'm not a "sober person who made a mistake". I'm an addict who made a mistake.

Most of us in 12-step programs have tried psychology (and counselling and hypnotherapy and...) before the despair was enough that we'd admit defeat and join *A. Admittedly, there's a cohort of people mandated to turn up. It should surprise no one that this cohort sees very high rates of recidivism. But I'd suspect the same to be the case for people mandated to attend psychotherapy. If you don't want to change, nothing can make you.

Pharmaceuticals are interesting. I believe that LSD has been trialled to help those with substance addictions but I'm not sure of the state of research regarding behavioural addictions.

Fundamentally though, the evidence is pretty clear that there's a neurological basis to most addictions including the behavioural ones. e.g. check the research of Mira Fauth-Buhler.

https://www.researchgate.net/profile/Mira-Fauth-Buehler

People can choose to identify as they wish, and I'm not for one second diminishing that identification. But problematic drinking is very different to diabetes, it's also highly varied in its expression and not as deterministic as the label suggests.

I totally understand why it's a helpful framing for some people, but it really isn't for others.

To extend this, there have been programs that have attempted to fix the problems of alcohol addiction but not require patients to remain sober. The core concept being that there is an underlying cause to the alcohol problem and the alcoholism is an expression of that problem, not itself a root. Thus once the root cause is fixed, the alcohol is no longer a trigger.

Another form allows participants to drink but uses a medicine which induces unpleasant effects from alcohol. Thus participants self train an avoidance pattern and break the positive feedback loop.

These should not be seen as contrary to the AA abstinance approach. For some people that appears to be the most effective means. For many other people, AA is not.

I suspect as we advance our understanding we'll come to find distinct subdiagnoses in alcoholism and alcohol abuse that suggest different treatment strategies. Right now our understanding feels very rudimentary.

> Another form allows participants to drink but uses a medicine which induces unpleasant effects from alcohol.

Actually, the successful medical method doesn't introduce unpleasant effects, but removes the pleasant ones and introduces 'extinction'.

The medication is naltraxone. Look up 'Sinclair method'.

> To avoid strong side effects such as nausea and vomiting, practitioners typically wait until after the alcohol detox process before administering naltrexone.

If you take one or two drinks, yeah it will just be not good. If you binge, you be puking your guts out.

This is not true. I have had ~15 drinks on Naltrexone which definitely qualifies as a binge although I never "truly" binged as I never blacked out after starting treatment via The Sinclair Method. It wasn't a great time especially the next morning but I didn't get sick at all.

I think I understand your point of view just fine. I have friends, family, and exes in AA and NA. I just disagree that the best way to treat addiction is a settled matter.

What I think is still up for debate is whether AA's framings are a net benefit, due to the lack of good research.

Your comment brings up standard AA doctrine, and I'm glad it's worked for you. But by your own admission, a lot of people fall off the wagon. You blame it on being court-mandated, but it doesn't seem to occur to you that another program may have worked better, court-ordered or not.

There's no consideration in your comment for survivorship bias in who remains in AA. Perhaps AA works great for a small subset of people, who stick with it, but is worse for a larger majority, who would be better served in a different program.

> Fundamentally though, the evidence is pretty clear that there's a neurological basis to most addictions

Uh, I'm not disagreeing. Not sure why you think I was? I used to chat about this stuff with Dr. Carl Hart, who studied meth addiction, when I was in grad school. He was also of the opinion that AA's efficacy was a black box, and said that he'd recommend Scandinavian outpatient facilities over AA, based on the research he'd seen.

Yes, the one thing we can do that we will surely bring us closer to curing alcoholism, is researching it extensively and coming up with a massive body of literature, and defining a system of taxonomic subclassifications of various alcoholism diseases.

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