1249: Rehab and Recovery | Skeptical Sunday

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Welcome to Skeptical Sunday. I'm your host, Jordan Harbinger.
Today I'm here with Skeptical Sunday co-host, writer, and researcher Nick Pell.

On the Jordan Harbinger Show, we decode the stories, secrets, and skills of the world's most fascinating people and turn their wisdom into practical advice that you can use to impact your own life and those around you.

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Today we're talking about drug addiction and rehab.

Whether it's you, a family member, a friend, a coworker, or even just somebody on television, chances are good that you're familiar with the subject of going to rehab.

It starts with hitting rock bottom, and then the family intervention where everybody gets all weepy and shares their feelings.

Then there's the 40 days of inpatient where they don't let you drink coffee or take your anxiety meds.

And it all ends with the perfect redemption of the person involved, provided that they attend 12-step meetings for the rest of their natural life.

That's how it works in Hollywood anyway, but what about in real life?

This model of recovery is based around the premise that addiction is a quote-unquote disease and that rehab is the treatment for that disease.

In fact, this model is so deeply ingrained in the American mind that lots of you are probably wondering why I'm even saying all this. This is all just true, right?

Well, what if addiction isn't a disease? What if rehab rehab often doesn't work? And what if it's less about recovery and more about business?

Are 12-step programs like AA really the only way for people to get clean? What does get clean even mean? Here today to help me kick the myths and clean up the story is writer and researcher Nick Pell.

Nick, have you ever been to rehab? In the words of Amy Winehouse, no, no, no.

And the only 12-step meetings I've ever been to were as moral support for friends of mine over 30 years ago. Weren't you in high school 30 years ago? I was in like middle school NAA meetings.

I knew a lot of people growing up who got into drugs and alcohol really early.

I mean, I knew kids who were doing acid in middle school. That is crazy.
That is crazy work.

It was a different time, but yeah, I suppose it is a little crazy. The thing is, though, I think it highlights something important.

So there's two guys I went to high school with who were daily acid users. Daily? Daily.
In school. Doing acid in school, first of all, sounds like a nightmare.

Yeah, and they were doing it pretty much every day. But back to these two guys, like they're, it's not scientific, but they're halfway decent case studies.
All right.

One of them, the last I heard, got into some serious trouble with the cops that was related to meth. Yep, checks out.
The other one is a carpenter in Hawaii with kids who smokes a ton of weed.

But other than that, he's one of the more well-adjusted adult human beings I know.

So I think there's this impulse to pathologize what's relatively normal, relatively harmless, youthful experimentation with drugs. I suppose.

But are you going to have this kind of understanding attitude when you catch your own kid smoking pot, though? Oh, absolutely not.

It's not that I never did drugs. I just, I never got addicted to anything but nicotine and caffeine.

So, you know, this one, mercifully or not, depending on whether you're one of the people who like me or one of the people who hate me.

There's going to be very little personal experience from my end on this episode. You do, however, know about some alternative views of addiction and recovery that the listeners might not be aware of.

Right. I mean, you outlined what people generally think of as recovery during the show open, and I think that's definitely real and works for some people.

But for other people, it might not just be ineffective. It might be the thing that keeps them abusing drugs.

These alternatives to AA and what we traditionally think of when we think about recovery are backed by evidence.

I'm pretty excited to get into the history of addiction and recovery and the way that we think about both, because I think most people just aren't aware that there's any alternative or even that there's a history to talk about.

When you say history, what do you mean? Are we going back to the dawn of time and cavemen getting hooked on poppy seed sandwiches or something here? No, we don't need to go back that far.

Alcoholics Anonymous was formed in 1935, and that's where we get a lot of our ideas about addiction and recovery.

Okay, so I'm guessing basically everyone has some vague idea about what Alcoholics Anonymous is and how it works.

But for anybody who is somehow not familiar, the claim is that they, I guess, cure alcoholism if you work through the 12 steps. Is that accurate? Ah, but here's the thing.

They don't claim they can cure it. Okay.
In fact, they say that you have a disease that lasts your entire life and never goes away.

And they assume that this is true of everyone who struggles with substance abuse.

The cornerstone of a lot of the way society thinks about addiction starts with the first step, which says that the alcoholic admits that they are powerless over alcohol.

This is the origin of the idea that alcoholism is some kind of chronic relapsing disease. Whether people know it or not, this is probably what they believe about alcoholism.

So, how does AA get the kind of dominance in the American mindset that you're talking about? So, from the 1950s up until Reagan privatized everything.

Oh, man, do I wish that were true? I'm sure you do.

But yeah, there's some significant privatization of social services, particularly during the first Reagan administration.

That's when these state-funded inpatient rehab centers pivot to private facilities with, you know, glossy brochures and Malibu sunsets.

It's during this era of privatization that the Minnesota model, which is what it's called, becomes so dominant that people just think it's the only way and the truth about addiction.

It's called the Minnesota model because it was first formulated in Minnesota. I have no idea what the Minnesota model is.
I'm guessing a lot of other people don't as well. What is the Minnesota model?

It's also known as the abstinence model.

The gist of it is that if you're an addict, which is a specific category of person, and an immutable characteristic of that person, you can't ever do any intoxicating substances of any kind, or that counts as a complete and total relapse.

Now, it's important to note that of the two guys who came up with the Minnesota model, neither one had prior experience treating addicts or alcoholics.

This is where the idea that addiction is a disease comes from. So, is there anything more to the Minnesota model than that? The addiction is a disease thing is definitely a big part of it.

Alcoholism is not a moral failing, according to them. It's a progressive, debilitating disease.
But the entire process we think of as getting clean is the Minnesota model.

12-step programs, detox, group therapy, probably most importantly, lifelong abstinence from everything.

Usually, not the thing that you were addicted to, but anything that might get you high. But isn't that what addicts need, total abstinence?

I mean, if you're a heroin addict and you sign up for methadone or Suboxone, you've just switched the drug that you're addicted to, right?

And I already know we're going to get listeners who are like, I never stabbed anyone, including myself, while I was on Suboxone, right?

That's not where, I'm not trying to argue that, split that hair just yet, but I guess what I'm saying is, is it really that much better?

Well, we're going to get into the Suboxone and methadone thing later separately, but let's just at a high level say, you know, I'm an alcoholic and I give up booze, but I smoke pot sometimes on the weekend.

Like, who cares if I do that? How is that related to my alcoholism? And is it a problem?

I think the the claim is that you have an addictive personality, so you're going to be addicted to something, even if it's not alcohol.

Well, there's not a scientifically recognized addictive personality. There are clusters of traits and risk factors that can increase the likelihood of addiction.

There's environmental factors, biological factors. It really is just a complex interplay of factors.
It's not some innate personality trait.

The DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, has substance use disorder in it, which I suppose gets close to this idea of a addictive personality, but the DSM has a lot of critics, myself included.

Yeah, Color Me Shock. So for the record, I don't have an addictive personality if such a thing exists.
Jen told me to stop smoking when I drank over a decade ago, well over a decade ago.

And, you know, as the guy who would drink with buddies and then they'd be like, let's bust out cigarettes. And I'd be like, I'll have one, right? I was doing that, which, you know, know, whatever.

We hate you, by the way. What, actual smokers? Is that what you mean? Yes.
Yeah, we hate you. So here's the thing.

I not only stopped smoking without a second thought and never, like, never craved it again.

I also stopped drinking more than a handful of times each year because I was like, I don't really need to do this either. Also, really without a second thought.

Look, I don't want to out myself too much, but I've tried a lot of harder stuff in my life.

And I maybe overdid that stuff on weekends, not recently because I'm too old for that crap, but I just kind of never thought about it again, right?

It's like there's people who can dip into that stuff and go to a party and be like, oh, that was kind of funny.

And then there's other people and it's like they dipped into it when I did in 2006 and then they're dead now or whatever. Right.
You know? Right.

I've done hard drugs a handful of times in my life and I have thoroughly enjoyed using hard drugs. Yeah.

But I've never once in my life thought, man, I really wish I could get my hands on some dope right now.

No, if anything, it's like, I wish I had the time, but then then if I did, I probably wouldn't bother with the dope.

I would just enjoy the Netflix part or like have fun at the party, not changing diapers or listening to somebody, you know, tell me why they don't like the blue fruit loops.

Anyway, let's, let's circle back. Somebody's had a day with their kids.
Can you tell? So let's, it was so hard to get Juniper in the car today, man.

She was, first of all, I don't know what the heck happened, but she's like, I don't want to go to school. If you think you're strong, you work out.

Have you tried to get a three-year-old into a car seat when they are hell-bent on not getting into a car seat it's actually almost impossible me and jen are both in decent shape and we are both sweating afterwards and we're just like how strong is our little girl we're actually kind of proud of her because it was it was like it was like trying to put a cat in a bathtub when the cat is as strong as a monkey that's what it felt like anyway

shall we circle back to a bit to how the minnesota model and the 12-step model became so dominant because while i understand the role that deinstitutionalization might have played in this, there has to be something more going on.

Well, what's going on is that 12-step programs are free. They're easy to scale.
They're widely known about. And thus they're deeply entrenched in both treatment programs and the courts.

Most judges probably don't even know that alternatives exist. And AA and its children, of which Narcotics Anonymous is the most famous, they dominate the narrative because of this.

Hence why so many people just take it as a given that addiction is a disease rather than a set of behaviors, or as some more extreme partisans would argue, totally fake.

And I know people are already trying to read into this what I think and you'll figure it out, but I'm not saying addiction is fake.

So well, what does the evidence say about the whole addiction as a brain disorder thing? That's the thing. The science on this is super mixed.

A big part, not the only part, but certainly a big part of the move toward the addiction as disease model isn't about science. It's about reducing stigma around addiction.

But there's a whole problem with reducing stigma around addiction if you reframe it as a disease that you're powerless against.

Because even if that's true for some people, which it may well be, there's very little evidence to suggest that it's true for all people who have substance abuse issues.

And this is not a neutral claim that it's a disease. It can actively harm people.
How would the disease model actively harm people? I don't understand.

Because if you tell someone they have no control over something, some may use this as a ready-made excuse to just not control it and not take accountability and not be responsible for their actions.

And again, to be clear, I'm not telling people to bootstrap their way out of a fentanyl addiction.

What I am saying is that there are certain people who will use this to their advantage and it's not good for them. And they may not even be doing it on purpose.

And it is probably true of some addicts but it's just very clearly not true of most people who suffer from substance abuse issues i guess i'm not even sure how you'd begin to quantify something like that how do you measure that kind of stuff or examine this most people just age out of substance abuse sources in the show notes right by the way like yeah there's footnote numbers here in my documents that uh that y'all can look at in the show because people go this is just a claim you made up and it's like literally nothing on this show that Nick says has made up.

The stuff I say is pulled directly out of my arse because that's my role on Skeptical Sunday.

But the stuff Nick says has been researched and all of that research is in the show notes for people who are already like fuming about this. Yeah.
Okay. So most people age out of substance abuse.

Okay. Tell me more.
Yeah, they do. Most people age out.
They either quit doing drugs entirely or they start doing them moderately. It's not conjecture.
Check the show notes. It's simply a fact.

Most people age out of substance abuse. And I think more importantly, the addiction model is just, it's unfalsifiable.
It has very scant empirical support.

There's nothing you can do to prove that addiction isn't a disease that people have no control over. And falsifiability is, that's what makes it a scientific claim.
Is it falsifiable?

You know, I think the universe was created five minutes ago by a dwarf who lives in the moon. and implanted all our memories in us.

You can't falsify it, you know, so it's not even a scientific claim that you can attack. Ultimately, I'm a proponent of whatever helps people regain control over their lives and keeps them alive.

That could mean moderation. It could mean total abstinence for some people.
It could mean harm reduction or medical assisted treatment, whatever it is.

But there's a lot of problems with the addiction as disease model. And we're going to explore them today because I'm the co-host and I'm the one who gets all these fun, cheery topics.
That's right.

Yes, exactly. You're like, you are here to propagate contrarian bullshit

with receipts. So let's try to bottle the topic.
Pun intended. Yeah, obviously, but I'll put a cork in it.

Ha ha ha.

Look, you want the dad, you get the dad jokes. But seriously, I wanted to talk about this because I know that addiction treatment is actually really big business.

That's what sparked this topic for me. Look, that's not necessarily bad.

Healthcare is big business and, you know, our healthcare system ain't perfect, but a lot of big businesses do good things for society. Let me put it that way.

But if people are having problems with drugs or alcohol or porn or any other kind of addiction, they should be able to seek help for it. And I'm a big proponent of that.

I also think that anytime there's a need for something, people are going to find a way to make money off that. Again, not necessarily bad in all cases.
All right.

So I can't help but wonder, how big of a business, how big is the rehab industry? It's a $42 billion a year industry in the United States alone. Okay.
Centers can cost between 30 and 60 grand a month.

Holy smoke. Higher end ones, you're looking at six figures every month.
That is nuts. How do people afford that? What do you even get for six figures a month? Now I want, maybe I need to go to rehab.

That sounds nice. There's no way it's not super cush at 100 grand or more per month.
Jeez. I'm not paying somebody to tell me I can't drink coffee in the morning.

I know a guy who's in rehab right now. It's on a farm or something.
His insurance paid for it, which creates the usual problems problems with the cost of healthcare when insurance gets involved.

And people may have different ideas about what the solution to this is, but I think that everybody probably knows like the cost gets blown up pretty quickly.

So, I don't want to know what kind of insurance pays that much. You know, what kind of what level of service do you have? How much is your premium when you're getting the 100 grand a month rehab?

Something tells me that they cap it at like five, but whatever. Okay, so are there any kind of standards for rehab places? How do we know if what they're doing even works?

There aren't national standards and it's difficult to know if what they're doing works because we first need to define success. Now, quitting completely is success for some people in rehab.

Maybe though, a rehab program could help transform a guy who is getting blackout drunk three times a week.

to a guy who can have a cocktail at a party once every two months or even you know a guy who has a couple of beers after work a couple times a week okay That to me would be success. Yeah, right.

But from the perspective of the 12-step model, this is a guy who apparently is just going to eventually go to slide backwards into getting blackout drunk three times a week. I don't know.

That's the thing that we have tons of evidence that people can do this. People can go from being heavy binge drinkers to moderate drinkers, moderate heroin users.
I looked for the article.

It's a million years old, but there was an article in Reason magazine like 25 years ago that was about white collar heroin addicts and it's like they were going to work at investment banks and hospitals every day and they're heroin addicts you know so we've had emails from listeners like that super highly functional ex-navy seal current heroin addict who works at like yeah i won't name the bank but at a bank and not i don't mean yeah like a retail line he's not a bank teller yeah right not there's anything wrong with that but this is a person who's making multiple six figures a year doing like spreadsheets between doing whatever they're, you know, shooting up a heroin.

Because I was going to say, like, oh, but I know this one guy, right, who couldn't quit on his own. Well, that's it.
We all know this one guy. And he's the,

you know, the reason he's that guy is because he can't control his drinking. He can't drink in moderation.
He is not the guy who success is. We get him to.
dial it back.

This is, you know, Barney from The Simpsons. He has one sip of beer and like, forget about it.
He's gone. You know, like, I'm not denying that that guy exists.

What I'm saying is that we immediately think of that guy because he's an outlier.

I'm guessing you and lots of people listening out there know a guy, not that I would resemble this guy at all, you know, who went from being a belligerent drunk who was getting blackout drunk all the time to a guy who enjoys a couple of Coors Lights a few times a week.

I don't drink at all, but I used to drink very heavily. I didn't go to rehab.
I just quit drinking one day. I definitely know people who were very heavy drinkers who are just moderate drinkers now.

And kind of the way that AA deals with this is they just go, oh, well, that guy's not an alcoholic.

And it's like, well, then if the proof of somebody being an alcoholic is that they can only recover your way, that's kind of strange. It's that no true Scotsman fallacy, right?

Like anybody who doesn't fit into our model is just not what we say our model does. It's like, well, okay, how useful is that for everybody who doesn't fit neatly into that particular cookie cutter?

Yeah, I mean, there's a good friend of mine back home who like, he was a really bad alcoholic and he had an experience that was, I don't even know what it is because he didn't tell anybody, but something happened one day.

He quit drinking. He threw all his energy into skateboarding of all things.
And he hasn't drank in like 10 years. He's never been to AA.
He's, oh, he's white knuckling it. No, he's doing pretty good.

He just, he likes to skateboard now. It's what he replaced him.

But the guy who goes from blackout drunk to modern drinker, like, you don't think about it because there's no story there.

What's the the story you know like oh that guy's drink a lot okay this guy just ages out of alcohol abuse into moderate healthy social alcohol consumption happens every day we both and everybody listening we all know people like this you know it's that comment yeah honestly that's most people that i know who used to drink i mean i i was gonna joke i feel seen but really like I used to drink my face off, man.

And then my body was like, hey, you want a 36-hour hangover with that?

And now, like I said, I have one cocktail every two months or something when it's someone's birthday and we go out or it's, you know, hey, they're known for their old fashions here.

It's like, oh, okay, fine. You know, why not? I'm skiing, you know, snowboarding.

But I think if you saw me in my late 20s, I have friends who, like party friends that I knew who I used to just hang out with and go out with that I knew in my late 20s and they'll reconnect with me on Facebook or Instagram or whatever.

And they'll go, hey, how are you? And I'm like, fine. And they're like, how's your business? I'm like, good.
They're like, oh, because I've never seen you sober.

And I'm like, that's so funny because, you know, that hasn't been me for 20 years, right? Or something or 15. So like, it's absolutely nuts.

And it's, they're like, yeah, we used to go out six nights a week and drink. And I'm just like, ugh, gross.
Like, it's disgusting to think about.

But if you'd met somebody, if you met somebody who says, I go and drink six nights a week, you'd be like, you need to get help immediately. Your life is going to be off

the rails. And me and a lot of those other guys are just big old nerds now with kids who don't drink.
Again, these are anecdotal.

This is all anecdotal and possibly outliers, but you're saying the data supports that most people are just like this? The data supports that most people age out of substance abuse.

It's again, it's in the show notes. Most people just, it's so normal that we don't see it.
Yeah. Pick your favorite drug.

And how many people you know who when they were 21 years old were doing ridiculous amounts of it and now are either moderate users or just quit.

I mean, you've seen me put back just disgusting amounts of alcohol. Yeah, we used to do it together.
That was our excuse.

Right. So I one day woke up and was like, man, I don't like how drinking, and I did.
I drank every day. I didn't drink to quite that excess every day, but I drank alcohol every day.

I just woke up one morning and was like, I don't like how this interferes with my recovery for bodybuilding. Right.
I'm going to quit drinking for a month.

see how it goes. And the month was seven years ago.
Yep. And I'm never like, oh man, I'd love to get a drink.
It's more just like, I've got a toast at a wedding. I think that's it.
I don't miss it.

And if anybody was going to fit this, like, you're an alcoholic, you need help. You know, it's like, I never lost a job.
I never did this. I never did that.
That's true of my father. He went to AA.

He hasn't drank in years and years, but like, I don't have any, like, the worst thing I ever did when I was drinking was act a fool. You're listening to the Jordan Harbinger Show.
We'll be right back.

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None of this, by the way, is to dissuade people from getting help. We're just illustrating.
At all, at all.

We're just illustrating that not everyone who drinks a bunch is an alcoholic that needs medical intervention, right? That's the point of this.

If you think you need help, you should ask somebody for it. This is an academic discussion about rehab recovery and the money behind it.

If you're you're listening to this and you're like, oh man, I thought I needed help, but like, I don't, just go get help. I agree with that.
That's a good discussion.

I absolutely do not want to discourage anybody from getting help. What are the metrics that we do have? How successful are rehab centers? Yeah, studies are all over the place.

There's no consistency because so much of it relies upon self-reporting. So it's very hard to verify sobriety other than trust me, bro.

And again, you know, if a rehab center turns a non-functional raging drunk into a functional social drinker, like, how is that not success?

Especially if it's maintained over, we check in in five years and it's like, oh, yeah, I had a drink at my kid's wedding. Who cares?

There's also not hard data on how people do when they check themselves into rehab versus when they're forced to go by the courts. And that's a big deal.
It lumps them all in together.

So we don't have that. And we also don't really have a ton of evidence on how 12-step works versus what's called evidence-based recovery.
Right.

I'm somewhat familiar with the scandals on the field like patient brokering, where people get kickbacks for bringing in addicts or centers that rely on relapse to drive repeat business, which strikes me as super gross, by the way.

You also talked about the high cost and how it's mostly not being paid out of pocket. It's being paid by insurance and passing the cost along to people.

That's not to malign any individual treatment center, but it is to say there's obviously some bad actors and some serious incentives for centers to be bad actors.

Particularly for someone who isn't an expert and is just looking to get their life in order, knowing what's a treatment mill and what's a good facility can be really hard to figure out.

People seeking treatment are kind of almost by definition very dysfunctional. And some of these centers can lean very heavily into weaponizing guilt and fear with their marketing materials.

Yeah, yeah, that makes sense. And it's an area that's very open to abuse and corruption.
You spoke a bit before about the difference between 12-step groups and evidence-based recovery.

So are you saying that 12-step is not evidence-based? This is maybe the big pop shell of the episode. It's not evidence-based at all.
Pardon me, this sounds really dumb, maybe, but what?

Because isn't evidence-based? Like, hey, we have data, this works. That seems like the base level requirement for a treatment program of any kind for literally anything.
Like, does it work?

Do we have any evidence that this actually does anything? No, but we're doing it anyway. Like, what are you talking about? How is that a thing? Well, the evidence that they were A works is anecdotal.

There are some studies that we'll about to cite in a minute, but to establish that they're effective, you need a control group, which we have.

It's called the people who stop abusing drugs and alcohol because they do something other than AA or because they do absolutely nothing but quit. Natural recovery is the term for that.

The Cochrane review is the biggest and best study that we have, and it found that AA is not significantly more effective than other methods. Tell me about the Cochrane review.
Who did it?

What's in there? The full title of this 2020 study is Alcoholics Anonymous and Other 12-Step Programs for Alcohol Use Disorder. It's a meta-analysis of 27 studies involving 10,565 participants.

It covers AA along with other professional efforts to get people into 12-step programs. Its findings are pretty nuanced.
And as always, it's in the show notes.

So you're going to want to, if you want to read it. So it's not just like AA sucks, don't do it.

No, it says some very positive things about AA, which performed as well or better than other approaches like cognitive behavioral therapy, motivational interviewing, or harm reduction in terms of abstinence.

And those last four words are the key. Got it.
Okay. So it works as good or better than other methods, provided that your goal is to completely stop drinking essentially forever.

The actual numbers here are 42% total abstinence from alcohol after a year for AA versus 35% for those in other forms of treatment. Okay, but a 7% edge, that's pretty good.

I guess most of the people aren't abstinent at all, but like 7%, that's, you know, seven people out of 100 whose lives aren't totally ruined. I'll take it.
And that's great and good for them.

And that's wonderful. I agree.
But it kind of gets to the heart of the issue with AA is that it demands total abstinence.

I also would argue that if the goal is total abstinence, it would be good to check in on these people in five and 10 years, but this did a year.

But again, like blackout drunk to a couple beers over the course of a week, that's considered the same thing. AA.
I see. From the perspective of whether or not you're sober.

I'm not trying to imply that people who are in AA are stupid and don't know the difference between a blackout drunk and a guy has a couple beers.

But in terms of what AA considers sobriety, those are the same outcomes for them because the guy who's having a couple beers a week is eventually going to backslide into the guy getting blackout drunk, which is not true, flatly, just is not true in every case or most cases, as we saw with people aging out of this.

So, when it came to simply reducing the amount of drinks a person was having, this is where it failed. AA did not consistently outperform any of the AA alternatives.
Got it. And how good is the study?

I know it had a lot of data, but is the study sound? Is this a good study to look at? There's a couple problems with the study, some of which are kind of baked into any study on recovery.

It's not randomized. It relies heavily on self-reporting.
It had a lot of dropouts.

The thing is, I'm just not sure how you're going to do this type of study without self-reporting and a lot of dropouts. Like, what are you going to do?

Lock people in a room and watch them them drink or not drink? No, thanks. I already went to college.
But yeah, that seems like a recipe to make sure people are drinking a lot.

What do you mean when you say evidence-based? What exactly are you talking about then?

There's mountains of evidence to support cognitive behavioral therapy, motivational interviewing, and contingency management. It's worth noting.

that all of these are going to define success as something different than total abstinence for everyone. Some people just don't have that goal.

Now, with that in mind, if your goal is total abstinence, they'll help you with that too. But the first thing you're going to do for some of these is figure out what's the goal here?

Where are the goalposts? Some people just want to get their drinking under control. And I think that's a fine goal.

And I think it's an attainable goal for some people who are struggling with alcohol and drug abuse. So most rehab doesn't really tend to offer this.
They tend to stick to the 12-step programs.

Do the rehab centers offer anything other than 12-step programs? Surely they do. Well, I think one thing they offer that's important, whether you do 12-step or not, is detox.

Because in some cases, like extreme alcoholism or opioid addiction, you absolutely need some kind of medical supervision while you dry out or the, you know, opioid language kick.

A big, big reason why people don't quit doing drugs.

is that they have real serious, grave, potentially life-threatening withdrawal symptoms that go beyond just, you know, oh man, I could really go for a drink right now.

How is detox different from rehab then? Well, detox is just the process of getting the drugs out of your system.

In the case of extreme alcoholism, most opioid addictions, this is essential and a medical issue. It's not a psychiatric one.
So you, you know, you may do rehab and detox.

You may do them at different places. You may not do 12-step for your recovery.
But if you're just like, hey, I'm going to quit drinking.

I've been rocking back for the Jack Daniels every day of my life for the last 30 years, you are not going to cold turkey that, my friend. Yeah, I see.

Detoxing without medically assisted treatment can be dangerous for people experiencing that kind or that level of addiction.

And, you know, depending on what you've been using, how much you've been using, it's not safe. Okay, because your body relies on that stuff somehow at that point.

Yeah, your body thinks alcohol is a normal part of its body. And when you take it away, it freaks out.
I see. Oof, that sounds miserable.

Is that what people are talking about when they're shaking and they're like, it's the detox tremors or something like that? I've heard of this before. You've seriously never had the shakes?

No, because no, me neither. Yeah.
Why would I have that? And I've talked to addicts many times and when I go, I've been to these like NA and AA meetings and stuff with friends.

And you go to Blimpy Burger or whatever afterwards, and they tell you, like, yeah, I got into this because

one day I was doing this, and then I started started having like DT tremors in the car and the police came and got me and here I am or whatever. Yeah.

Another thing you talked about is that addiction isn't a disease. Okay.
So if it's not a disease, what is it? You could model it as a compulsion or you could simply model it as a choice. Okay.

Like everything else people do. So dumb question.
Why would anyone choose to do drugs? People do drugs because they're fun. Yeah.
You know, I mean, that's like, of course.

But you know what I meant by that question, right? Yeah, yeah.

but you know like oh man why do people do drugs they're fun as hell the question is why people keep doing drugs when they're ruining your life because that's the real question right and the answer might be that they're choosing to avoid the discomfort of not doing drugs by doing drugs even when this has disastrous results for their life.

It may be something deeper than that that causes them to seek out the relative comfort of drugs. And you would want to address that rather than the drug use per se.

Now, the choice model comes from an alternative program called the freedom model.

And I'm not saying that this is for everyone, but I am saying that it's good for people to know that there are alternatives to AA and 12-step. And the freedom model is possibly the biggest one.

So what are some of the key differences between the freedom model then and AA? One really good example is that, you know, AA says you're an alcoholic. This can't be changed.
You just are.

You quit drinking today, live another 60 years without even thinking about a drink, but you're still on some ontological level. You're an alcoholic.
Okay.

Like my father hasn't drank since like Ronald Reagan was in office. He's, I guess, an alcoholic till the day he dies.

But The other thing in this model is that if you have even one drink after 50 years, like, oh, there goes this sobriety.

The freedom model says addiction is not a permanent identity, that people can and do change their habits and indeed their lives without being abstinent from drugs and alcohol for the rest of their lives, without the peer accountability of AA.

And they say that drug use is a preference and not a compulsion. You do it because you want to do it.
The freedom model is not the only alternative.

We talked about cognitive behavioral therapy and other methods. There's also smart recovery, which leans heavily on cognitive behavioral therapy.
Life Ring, which is very self-consciously secular.

It's not all that different from 12-step in my understanding of it in that, but without the, you know, requiring a belief in a higher power.

There's harm reduction, which just says, okay, this guy's an addict. Let's make sure he doesn't die.
Right. You see that it raves, right?

The harm reduction people where they're like, we know a bunch of you are on NDMA and ketamine or cocaine or whatever the heck. We have water.

We have a place where you can sit down and people aren't going to be bumping into you and you're not going to be confused or scared.

We can call the EMTs for you because we know you're not going to just don't do drugs, kids. Like that's not realistic.
You're at a, you know, whatever, Lollapalooza or something.

So like, or, or maybe not quite that.

You're at a warehouse party, an abandoned warehouse in downtown Detroit that where half of it burned 20 years ago and there's a rave going on in here today. Okay.

So that harm reduction is, it's an interesting one because it just sort of accepts that people are going to do it.

And it's like, let's maybe don't just leave them on the side of the road if they start convulsing.

And there's overlap between people who are very active in harm reduction and people who are very active in different sobriety communities.

So I think it's not so much that they like, you know, oh, well, people are just going to do drugs. So who cares? Let them do it.

But, you know, they understand that people do drugs and we don't want them to die or anything like that.

The freedom model is arguably the most famous and most successful of these AA alternatives.

I think one of the most important points to highlight here is that, yeah, like not everyone wants to quit doing drugs. A lot of people don't.

And what many of these people want is they actually want to be able to use drugs and have a normal life. They want to be able to eat their cake and have it too.
Eat their cake and have it too.

Is that not backwards? No, no. The Unibomber was arrested, in fact, because much like me, he was pedantic about using this the correct way.

Wait, so I've always thought it was have your cake and eat it, too. That's what I've heard my entire life.
It doesn't make any sense, and it never made any sense to me.

So you're telling me that I guess I was kind of right, because you're right. It should be the other way around.
That makes way more sense. You eat your cake, but then you still have it.

Not have your cake and eat it too. I don't know.
I guess. Tell me more.
If you go back into the linguistic history of it, it's the older use.

And Ted Kaczynski, the Unibomber, was so super insistent on saying this the correct way that it's in his manifesto.

And his brother read his manifesto when it was published in all the newspapers when we were in high school and went, oh, that's weird.

My crazy brother I haven't seen in like 20 years used to say it that way. Wow.
And so he was like, hey, this is a weird hunch, FBI, but I'm just saying, I got a brother who's a little bit nuts.

And he's the only person I've ever heard say this exact phrase. Yeah, it was that and like other weird stuff.

Like his manifesto used the style style guide that you would have used as a Harvard grad student in the late 60s and he had like weird spellings of words that only appeared in Chicago newspapers in the 50s.

That is bizarre and interesting. Also, kudos to whoever figured that out.
That's amazing to figure that out without the aid of AI.

Like you could use AI to figure out something like that, maybe, but somebody to do that manually, holy smokes.

That's well, when you read it, it's like, it's weird, you know, like some of his spellings are like, that's not how anybody spells that today.

It's like, yeah, because this guy hasn't read a newspaper since 1971.

So it's like if somebody writes encyclopedia, but they write P-A-E-D-E-I, or they use the A-E thing and you're like, this person is either British or just a big weirdo or both. Yeah.
Okay.

Anyway, what's the evidence like in terms of how well the freedom model works? I think the first thing we have to say is that works is defined very differently in the freedom model.

Each and everyone gets to determine their own goal.

That could be total abstinence, could be moderation, could be going from being being our blackout drunk guy every day of the week to, I just want to binge drink on weekends and be fine to go back into work or our functioning heroin addict.

You know, well, I was living in a gutter. I'd love to be able to keep doing heroin, but maybe I just do it on long weekends or something.

The point is to take control of your substance abuse and make it intentional. So the Freedom Models authors claim a 62.5 success rate with total abstinence over five years.

That's a non-peer-reviewed statistic based on graduates from the St. Jude Retreat prior to it being rebranded under the name the Freedom Model.

It reportedly included individuals who voluntarily completed the full curriculum, not those who dropped out. That seems like a pretty big

asterisk to hang over that. Survivor bias, anyone? Yeah.
Yeah, there's some survivor bias in there for sure. And as usual, there's no control group because how do you get one? Yeah.
It's difficult.

And they have none at all. So I'm unclear if what they mean by total abstinence means that the participants met their own definition or not.

And there's also no clarity on relapse, recidivism, long-term outcomes. I mean, none of this is really making the case for me, man.

You know, I got to be honest here.

It wouldn't be terribly compelling for me either, but for the fact that it squares with independent research on self-healing, what is called natural recovery, which I mentioned earlier is people kind of aging out of it or waking up one morning and going, I don't think I'm going to drink anymore or I'm going to drink less and doing it.

The National Epidemiological Survey on Alcohol and Related Conditions found a 70 to 75% recovery rate for people using what we are calling natural recovery.

Stanton Peel did a bunch of research that found that changing your life circumstances was a much more successful predictor of recovery than surrendering your life for the disease of addiction.

Who is Stanton Peel? A psychologist, attorney, and public health expert who has been one of the most prominent critics of the addiction as disease model over the last 40 years.

He runs his own peer-reviewed program, the Life Process Program. And the most important of the papers that he has written is called People Control Their Addictions.

Even the title is controversial, I think. Yeah.

No, but that's his thesis is like, you're in the driver's seat here. And kind of, as I've said throughout, I think this is true of some people and not true of other people.

And everyone can, you know, the papers are in the show notes and people can go look at the data and see what they say.

And they can decide if, you know, they think he's onto something or if he's blowing smoke.

A number of his studies and other studies have cast doubt on the predictive power and utility of the brain disease model that's very, very ingrained in both the Minnesota model specifically and our ideas about addiction more generally.

You're listening to the Jordan Harbinger Show. We'll be right back.

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Now for the rest of Skeptical Sunday.

But you're also not saying that AA never works for anyone or anything like that, right? No, but obviously people are going to hear that. Yeah.
You know, but no.

I'm going to get those emails from people who listened to five minutes while on the treadmill at the gym and then angrily threw their phone down and then walked over to pick it up just to email me, having not listened to anything else in the episode.

Some guy's going to be on the treadmill texting his wife, being like, Babe, Jordan has Nick Pell on talking about how I should quit AA.

This is absolutely not what I'm saying.

No, I think that honestly, if from my perspective, and I think that this is an important point of view, I don't think it really matters if the addiction as disease model is true in a scientific way, it may very well be a useful fiction, even if it's not true.

You know, some people might need that identity and that model to have success. If this model works for you, if the science doesn't back it up, I don't care if it gets you clean.
Yeah. Who cares?

But the whole rock bottom, then surrender to disease, 12-step experience is far from universal.

And even if you do decide that total abstinence is the choice for you, that does not mean it's the choice for everyone. I haven't had a drop of alcohol in seven years.

I'm not saying everybody should quit drinking.

And it also doesn't mean that AA and other 12-step programs are the way to get to that total abstinence, that they're the only way to get to that abstinence. The freedom model.

and Stan Peel, I think what they offer people is agency. AA makes them a victim of something beyond their control.
And the freedom method says, you're in control of your life.

You're responsible for your own choices. Right.
But if I'm allergic to peanut butter, I can make a choice to eat it, but it's just, that's an incredibly stupid choice. But the choice is still there.

Okay. You know, again, not saying that everyone can moderate their drug and alcohol use because I'm very, very reticent to apply one broadbush to all people.

I just don't think the world works that way. I very rarely think that there's a one-size-fits-all approach that works for everyone.

It is worth noting that there are tons of people who are 12-step program quote-unquote failures who finally found what they were looking for in the freedom model and Stan Peele's methods, other alternatives.

How many trips to rehab are coerced or court-ordered? Like the person has to go there, basically.

I mean, this is kind of the $64,000 question, and I suspect it's doing a lot of work in terms of why rehab doesn't work for a lot of people. Maybe it's their methodology.

Maybe it's just that so many people don't want to be there or are begrudgingly there.

The actual data on this is super hard to sort out, but up to half of rehab check-ins are court-mandated and up to half of them are because of pressure from family.

So depending on how we interpret this data, it's entirely possible that like statistically everyone in rehab is there because their family is twisting their arm or the courts demanded they go.

I'd imagine that doesn't exactly set the person up for success, right? If you don't want to be there, you're probably not going to engage with the program as much.

And as a result, you're maybe not going to get the best results. Right.
And that's not conjecture. We have data on this.

When people go to rehab because they have to or even because they feel like they have to, the results just aren't as good. So that's another factor floating around in the soup.

And I suspect it's a factor in the AA's numbers that when we were talking earlier about, you know, AA's numbers aren't great in these areas. And it's like, well, yeah, how many people are in AA?

Because a judge told them they had to go. Yeah, so it affects every recovery type.
Yeah.

So do you then think there's a similar issue within the freedom model and the 12-step alternatives you talked about?

I think that there may be some coercion going on in terms of like wife, mom, whoever says you have to get some kind of help. But I could not find a single example.

of somebody who was forced to go into one of the alternatives to traditional 12-step programs by courts.

The closest thing that I could find is that if you do get court-mandated AA, you have a legal right to choose a secular alternative. That's thanks to a court case called Hazel versus Crowfoot.

It kind of strikes me as unlikely that people are going to get pressured. Like, you have to go do the freedom model because like nobody's heard of it.

And, you know, also, I get why families would maybe be skeptical of the alternatives, particularly ones like the freedom model.

Because your raging alcoholic uncle says, well, I'm not going going to quit drinking, but I'm going to moderate my drinking. I found a program that says I'm not an alcoholic.
Right.

You're not really going to bite on that one, probably.

Right. Yeah, that's a good point.
I can definitely see why people would hear that and think, Yeah, sure, Uncle Bob, whatever you say, as he like falls down the living room stairs.

And I get why courts want to direct people to treatment rather than to jail. And I think that's probably the right choice for a lot of people.

But if people are just going to go through the motions to get the court off their backs, it's not going to end well in the long term. No, it's not.
And we know this.

I don't really care how we deal with drug abuse as a society. I would like to see fewer addicts.
I would like to see no people dying from drug overdoses.

Beyond that, the details are like, this is above my pay grade. I don't have a master's in public health to figure this out.
Anecdotally, back to the jail thing, I have met some older addicts.

heroine who told me that they were able to kick their addiction because they went in a lockup for a weekend and they had to detox in a, you know, cell.

And when they got out, they were just like, I'm done. I don't care.
I just want people to not be addicted to heroin or fent. And I don't want them to die.
That's really my only strong position here.

Injection sites, Neil Swaps, I have no idea. Like whatever works, let's do that.

I can see how you can't punish people into sobriety, but I can also see how punishment is maybe the thing that makes some people come around eventually. Right.

And well, I think it gets back to what you were talking about earlier, right? Different people recover in different ways. Tons of people talk about rehab.
They say it saved their lives.

Other people recover without rehab. Lots of people just decide to quit one day and somehow it sticks.
And I think you're right that the problem with AA isn't AA as such.

It's that it's framed as the only way that exists for people to get sober. And that's not true.
That's just not the case. Right.

And that's kind of like my only real beef with it is, you know, if you've done AA six times and you keep failing it on step three, maybe you need to try something else, which is ironic considering that I believe it's them who say the definition of insanity is doing the same thing over and over again and expecting a different result.

Unless it's AA, in which case keep coming.

Yeah. Yeah.
And then there's like, well, they didn't want it hard enough. And it's like, no, I think they really want to get sober, but this just isn't working for them.

And, and maybe it's, maybe they're the problem. Yeah.
It's impossible to say. It's just that one answer is not the correct one for everybody.

If we totally rebuilt the system from scratch, I think it would mostly be about balancing all the options out there, making people aware of all the options out there, outpatient care, harm reduction, medical assisted treatment.

I know people are critical of medical assisted treatment, but I lost a friend to a heroin overdose some years back, and I would much rather that she was alive standing in line at the methadone clinic every day than dead.

So I don't care if people want to go be suboxone addicts as long as they are walking around alive. Yeah.
No,

I think we can all mostly get behind that. I'm aware of medical assisted treatment.
That's where people take a drug that helps them deal with withdrawals and stuff like that.

And in some cases, it can become a sort of new addiction. And I've gotten messages about this on Instagram, like, hey, man, yeah, I'm hooked on suboxone.
So effing what?

I think was the message I got recently. But the thing is.
Almost nobody's dying from methadone overdoses. And we don't criticize diabetics for taking insulin.

So if we think that addiction is a disease, why are you criticizing people for taking a drug for their disease? I don't get it. I don't either.

I mean, and I think that like if somebody's quality of life is impacted by their suboxone addiction or their methadone addiction that they're using instead of heroin, there's probably ways for them to transition off of that.

But if somebody's functional, you know, like I said, I just, I prefer them alive is the main thing. And I think this all goes back to what's the goal? What is your goal here?

If the goal is simply to live a functional life, I've definitely known way more functional methadone addicts than functional heroin addicts in my life. And I've known a fair bit of both.

There's nothing immoral about being addicted to any drug. The issue is generally the things you do to support your addiction.
Right.

And I don't know anyone who's mugging grannies to pay for their Suboxone or their methadone or you know, any other nefarious or degrading things that they could be doing to support an addiction.

People People aren't doing that. Yeah, I love caffeine.
I don't know if I'm addicted to it, but I'm not going to mug any old ladies to get my fills in the morning or Starbucks for that matter.

I might. You might.
You might. With your nicotine, man, I don't know.
I wouldn't, I don't know if you'd mug me. You might not attack someone to get the nicotine.

You might attack someone because you can't get the nicotine, right? It's just, it's a mood. It's more of a mood thing.

But there's also a stigma against addiction that I think potentially prevents people from getting help early.

It's like, oh, I don't want to have to go in right now because then I have to admit that I got this and I have to take time off work because of this.

So we have this whole narrative of hitting rock bottom where people have to just ruin their lives, right? It's like you have to lose your kids and your spouse and your job before you seek help.

And I can also see, and some of that's the issues with addiction, but a lot of it is the stigma, I think.

And I can also see that there's just a greater chance of somebody seeking out help on their own if they're pitched on moderating their drug or alcohol use rather than being like, you can never do this again, ever.

Yeah.

And to me, in fairness to AA, they do talk about high bottoms, like people who have their bottom is not dying in a gutter or, you know, running over a child while they're drunk or something really extreme.

But yeah, I mean, one of the problems, though, is with the 12-step stuff is that the aftercare is just like go to meetings. And I think a lot of people need more than just peer support.

I have heard from people in AAA that sometimes they can be critical if you are getting professional counseling in addition to AA. I don't know how true that is.

It's just something people in AA have told me. I'd like to see a lot more data collected so we can just have a better idea of what works and what doesn't.

You can't have evidence-based therapy without evidence. What about people looking for rehab centers? What should they be looking for if they decide that that's the right track for them?

Well, again, people need to remember treatment is not one size fits all, or at least it doesn't have to be.

So the first question I'd ask is, do you only do 12-step here or do you incorporate other methodologies? These all sound obvious, but like, what are the credentials of the staff? Are they licensed?

How do they handle relapses? Is it more punitive? Is it supportive? How do they feel about medication-assisted treatment?

Is methadone considered breaking your sobriety or is this a, you know, life-saving treatment for opioid addicts? What's the aftercare like? What are they going to do?

for you after you graduate from the program and most importantly i think what's the track record Do they even track outcomes? And if so, what are they?

There's got to be some red flags that people need to look out for if they're searching for a rehab center. What might some of those be?

So this is a great pivot to get back into the darker side of rehab. There's just so much overlap with red flags and what is wrong with the rehab industry as a whole.

So I mentioned this is a $42 billion industry. That doesn't make it bad.

But when anything starts being that lucrative and producing that much revenue, you always have the chance that people are going to start seeing it less as a way to help people and more of a way to make money.

And that's how we get the Florida shuffle. Okay.
That sounds like a new dance that's popular with guys on gas station bath felts.

It's actually the term for when people keep relapsing and just bounce around different facilities. So apologies to people in Florida.
I did not invent this term.

It's kind of a shorthand for the abuses of the system. So remember, most of the time, People seeking treatment are not paying out of pocket.
Their insurance is paying.

And when that happens, bad actors can definitely use this as an opportunity to bill baby Bill. As a lawyer, I definitely know what that term means.

Yeah, taking a piss while typing some notes about the case into my phone, that'll be $200.

Man, you're really going to tell everyone about the times you billed a guy to answer a text while taking a piss at a club? I mean, it was an email. And yeah, I think I just did.

This is like one of the first things you ever told me about yourself, by the way. And I thought it was awesome.
Yeah. I mean, look, I did the work.

I just happened to have my dong in the other hand because I was drinking. It was qualified.
The primary victims of the Florida shuffle tend to be young because they're stolen their parents' insurance.

Right. The other big example of abuses in the system we see is patient brokering.
Rehab centers will pay kickbacks to sober home operators or even just independent recruiters to bring in patients.

Some brokers will get insurance for these victims just to bill them. Oh my God.
That's illegal. It's illegal.

How is that legal? But it might.

Well, good thing we have laws against things, so they never happen. Right.
Yeah. Sheesh.
Yeah. So, you know, both of these are weaponizing people's relapses for profit.

It's like if your hospital made money off of your cancer coming back. Hospitals do actually make money if that happens.

By the way, that's right. It's not a good analogy for that reason.
But

you understand my point. It's like they purposely left cancer in you for it to grow back.
Right. Okay.

So there's obviously a conflict of interest here, but part of it is just endemic and baked into the system. I'm not sure how much you can actually do about it.

It's just kind of like, yeah, life sucks. Get a helmet.
There's bad people in the world. They're going to do bad things.

I'm not sure how you make helping people to full recovery into permanent total abstinence more profitable than the same guy relapsing 10 times in two years. Like, how do you do that? I don't know.

Yeah, no, you're right. And if they're billing insurance, I'm willing to bet they're billing outrageous amounts of money for simple procedures and treatments as well, right?

So you're talking about like the $30 Bandaid kind of deal. Oh, we're talking about $31,000 in urine test charges over the course of a month, which is real.

And in the show notes, that is some expensive piss. Given my previous relatively small time urine-related billing, I got to say, I'm quite envious.
$31,000 in urine test charges over a month.

How does that even happen? Yeah, you got to ask about how they bill. Ask if they work with brokers.
And yeah, ask about the track record.

If you're listening to the show, you're probably pretty smart and you're going to know red flags when you see them, but just a little checklist for you. Right.

You need to do more due diligence about a $50,000 rehab program than you do about a $5,000 used car.

The takeaway here is not, by the way, everyone who's angrily emailing and halfway through, it's not that rehab is a scam. It's not.
But there needs to be more scrutiny over the system in general.

The 12-step programs, they work for some people, but for others, it can be actively harmful. And in any event, it's not the only option out there.

We need an evidence-based, nuanced approach that's tailored to the individual seeking treatment. And it's got to be transparent.
It's got to be be more honest while also being less judgmental.

And by the way, if you are struggling with substance abuse issues, you should know that people can and do either quit completely or moderate their use. You can retake control of your life.

Don't feel like you have to wait to hit rock bottom before you reach out. We've put some resources in the show notes for people who want to get help.

And I sincerely hope that you do because I can't afford to lose any more listeners, folks. That's the truth of the matter.
So I want to keep you around. Nick Pell, thank you very much.
My pleasure.

We worry about secret societies online, but the real danger may be hiding in trusted institutions that we see every day. I'm a financial reporter by background.
I basically fell into this rabbit hole.

And so I began to dig. And this Spanish priest called Jose Maria Escriva dreamed up this kind of group which called itself Velpus De, which is Latin for the work of God.

He saw his followers as part of this hidden militia that would infiltrate society and use their positions there to basically push society in the right direction.

And he literally tasks them with infiltrating government, business, the world of education, becoming journalists and kind of using their positions there to be this guerrilla reactionary force.

The thing that makes this so much worse is that this is an organization which has been legitimized by the Catholic Church. It has the stamp of approval from the Pope, from the Vatican.

The way that Opus Day operates is that it's using scripture to push back on anything progressive and for anything kind of left-leaning. And it's a misuse of religion, really.

I think the vast majority of Opus Day members, they don't have a clue about this human trafficking and the way that, you know, certain members are being drugged, labor trafficking, I mean, grooming of children, all kinds of kind of financial fraud and spiritual fraud as well.

All of these abuses going on, I think... They would be absolutely horrified to find out what is going on inside the organization.
They have thousands of members. The network runs far and wide.

Assets in the billions. Anyone that isn't part of Opus Day is an enemy of Christ.

Gareth Gore uncovers how Opus Day built a global empire of secrecy and why dismantling it might be the fight of our time. Check it out on episode 1170 of the Jordan Harbinger Show.

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Finding a great new podcast can feel like searching for a needle in a haystack.

Let me save you some hassle. Check out Something You Should Know with my friend Mike Carruthers.
Every episode is packed with fascinating insights that you can actually use.

Mike interviews top experts on topics that shape your life, like how to optimize your brain chemistry, the best and worst ways to apologize. Probably could have used that recently.

Why couples hate to talk about money. No matter the topic, Mike asks the questions you'd want to ask, getting straight to the good stuff.

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Look for the bright yellow light bulb and start listening to something you should know.