Steve Martorano 
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The Behavioral Corner 
Hi, and welcome. I'm Steve Martorano, and this is the Behavioral Corner; you're invited to hang with us as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and well-being. So you're on the corner, the Behavioral Corner. Please hang around a while.

Steve Martorano 
Hi, everybody. Welcome back to the Behavioral Corner today. I'm Steve Martorano. Here's what happens on the Behavioral Corner. The conceit is that I'm on a corner, but you can see that I'm not. And it's the intersection of lots of interesting people, and behavioral health. We call this a podcast about everything because everything affects our behavioral health. And it mentioned it's all made possible by my underwriting partner Retreat Behavioral Health, you'll hear more about them later on down the road. Our guest is welcome back to the program because Maia Szalzvitz, which has been with us in the past, Maia is an opinion writer at The New York Times, she covers addiction and public policy. In addition to that she's the author of a couple of books, brilliant books, undoing drugs, the untold story of harm reduction, and the future of addiction. We do a lot about harm reduction around here. And her other book is entitled, unbroken brain, a revolutionary new way of understanding addiction. We welcome Maia back to the program. Thanks so much for doing this.

Maia Szalavitz 
Yeah. Thank you for having me.

Steve Martorano 
Do you write the headline and the titles of your essay pieces?

Maia Szalavitz 
Yeah, the I mean, what's interesting is like, I can suggest things, but then they'll do whatever they're going to do. They also like to do this A/B testing. So like, they'll try a headline, and they'll try and alternate and whichever one gets the most clicks wins. That's really not up to me.

Steve Martorano 
I don't think a lot of people are aware of that. That's a distinct skill set at a place like even the New York Times, but it's certainly a skill set on the internet. Clickbait is clickbait. Nevertheless, at the time, it is not famous for clickbait...

Maia Szalavitz 
We're just trying to get people to read.

Steve Martorano 
...and this caught my eye because the essay that brings me to us today is entitled People Have a Right to Nonreligious Rehab. Okay, so let's begin with my question. I wouldn't think this was a problem. First of all, what do we mean by nonreligious and why has it become a problem?

Maia Szalavitz 
Roughly 90%, of residential treatment in the United States, focuses on teaching people the 12 steps. And the 12 steps involve surrendering to a higher power, taking moral inventory, and all kinds of things involving God. The program's response to being called religious is, "We're spiritual, not religious." But every court that has ever ruled on the question has ruled that is religious, it is deeply rooted in the Christian tradition. And in a specific Christian revival movement.

Steve Martorano 
Yeah, the Oxford group is the origin of AAA. And that is clearly a faith-based group that was dedicated to employing God and faith in dealing with alcoholism. I get all that what the new state courts have ruled consistently, what sort of cases would they be ruling?

Maia Szalavitz 
Well, like, there was a recent case where a Buddhist pilot did not want to go through the 12-step-based treatment that, unfortunately, is forced on all pilots, and still seems to be from what I can tell, if you look at their website, it's just 12 step all the way down. But he was like, I'm a Buddhist, I don't want to do this Christian thing. And so I can go to I think it's called refuge recovery. Why aren't I allowed to do that? And the courts is to the tune of, you know, I think a few $100,000 or more, yes, you are entitled to do that. Because this, you know, is forcing you into a different religion. So there's been other cases where people get court-mandated, you know, to go to AA, for various reasons. And again, like every time they complain, when they're not given an alternative, the courts have said, No, you can't force people to do this, because it violates the First Amendment.

Steve Martorano 
How do we arrive at the how do the courts how do we arrive at a clear understanding that the 12 steps are Christian?

Maia Szalavitz 
Well, I mean, they say it explicitly. Look at the history.

Steve Martorano 
I don't the about the 12 steps. I mean, there's plenty. I mean,

Maia Szalavitz 
not in not in the actual literature so much, but you'll see that there are all kinds of sort of arguments over time, about making it appear less Christian. Also, you don't hear the Lord's Prayer in mosques or synagogues. But you do hear the Lord's prayer at the end of many 12-step meetings.

Steve Martorano 
Where they run out autonomously, there's no central organization mandating that they do anything, for that matter. No.

Maia Szalavitz 
And I mean, I think like, again, I am not saying that 12 stuff is bad, or that religion is bad, or that, you know, it's, it's a bad thing to take a moral inventory, I think we should all do that. The thing that I have a problem with, is that it implies faith in a Christian God, basically. And you could get away with a Jewish God, or maybe a Buddhist one, maybe Islamic. If you look at the way the steps are written, and the idea of how God intervenes in your recovery. It's pretty much a Christian concept, and certainly a concept of a God who cares. A God who doesn't care like a doorknob is really not going to be able to restore you to sanity as the second step says.

Steve Martorano 
Yeah, the doorknob is the famous sort of finesse move, they say can be anything greater than yourself. It could be even a doorknob. And you know, what you've talked to many people who've been through 12 steps, they sort of dismiss that -- they don't dismiss the notion of faith or God. But they do dismiss that concept.

Maia Szalavitz 
I went to 12-step meetings every day for five years. So not unfamiliar with the ins and outs.

Steve Martorano 
Okay. Well, let me ask you this. I don't want to we're not here to debate that because I agree with you. First of all, the idea that the state should mandate, any sort of treatment is a little scary, to begin with. But certainly, you're right, and the first amendment would preclude them from doing it in a strictly Christian context; you have to go do this. And it's clearly a Christian concept. But those arguments are slippery for me. I'm surprised. More lawyers haven't stood up and said, Well, wait a minute. It's not Christian. It's God. Okay. But let's stop it...

Maia Szalavitz 
But God is religious in itself.

Steve Martorano 
That's my point, though. My point is...

Maia Szalavitz 
A lot of these cases have been by atheists.

Steve Martorano 
Well, that's my question. They have a standing in this, that makes more sense to me, that they should say...be able to say clearly, you don't understand. I don't believe in any sort of greater power than me. How can you force me to take a program that insists you surrender to a power greater than yourself? They've been successful as well, I'm sure, right?

Maia Szalavitz 
Yes, a lot of these cases have indeed been atheists or agnostics, or people who just don't believe that there is a personal God that intervenes.

Steve Martorano 
So for people who are maybe new to this, this notion and your work in this regard, I wanted to be clear about this. We talked about it before we started recording, you're not here to say 12 Steps doesn't work, or that it's bad, or that it should be outlawed. You're just saying it shouldn't be mandated by the state.

Maia Szalavitz 
Exactly. And I'm also saying that we shouldn't have payers paying for it. When I went to treatment, which was a long time ago, admittedly, I hear from people who went far more recently that get the same kind of thing. Almost all of the content in the therapy in the groups and everything counseling was about getting you to accept the 12 steps and getting you to accept the ideology of powerlessness of hitting the bottom of enabling all of these things, which when you actually look at them, scientifically, are not accurate, or at least not accurate for everyone. I think some people absolutely find help in ideas that aren't necessarily provably true. And that's fine. I don't want anybody whose recovery is working, they should do what they're doing and keep doing it. My problem is for people who go to treatment, like if I went to treatment for depression, and I was told to take a moral inventory, I would be pissed, you know because it would be implying that I'm a bad person. And a lot of, you know, the idea that moral inventory is needed, and that people with addiction have special character defects that are different from other human beings. It's just false. Like certainly some of them do. But the reality is that like, we're not all antisocial. And we're not all people who would mug grandmothers, like the whole idea that like that's a yet like, I haven't mugged my grandmother yet. Know that like, it's just never going to happen.

Steve Martorano 
How do you answer someone who says, Well, I think you're misreading what moral inventory is all about. I did a lot of terrible things under the influence of substances that I was abusing. I'm not saying I'm a bad person. I'm saying I did bad things. When I was using I'm just here to tell you, I recognize that I did those bad things.

Maia Szalavitz 
That's fine. I have no problem with people taking moral inventory, I have a problem with the rehab, or a psychologist or a medical professional telling me that that is essential for recovery from addiction. When we know that that is true, it can certainly help some people. I mean, I found it helpful, because I found it helpful in the way that, you know, I always thought I was a terrible person. And I sort of found out that I wasn't quite that bad. But there are serious problems with the way the moral inventory in the fourth step is written, which asks you to look for your part in what went wrong. And that is really bad for survivors of sexual abuse, rape, and child abuse and all manner of things that they had no part whatsoever in experiencing. And that can be really harmful to people. Like I have talked to survivors who were told, Well, how did you seduce the like man who raped you when you were three? Literally, I'm not exaggerating, they really took that literally. Now thankfully, the vast majority of people don't take it that literally and they recognize it was written for white arrogant men, not for, you know, women who actually resented their sexual abusers, and rightly so. You know, so I just think that if we're going to pay as a government, like Medicaid or Medicare, or insurers, if we're going to pay for treatment, it has to be based on evidence. And the idea that, for example, people with addiction have special moral defects that are not seen in other people. And that caused the addiction. That is just not true. It may be true for some people, but to see that as the only valid way to see addiction, and to see this as the only pathway to addiction is...to recovery, rather, is really harmful. And again, I have benefited from the 12 steps, I think they can do wonderful things for people. I just feel that given that we know that they definitely don't work for everyone. And given that we have alternatives that do not present these First Amendment issues and are not available everywhere for free. Why the heck are we spending $1,000 a day or whatever we're spending on a rehab, where you could just sit in eight meetings and get that same content?

Steve Martorano 
Maia Szalavitz is our guest, she's an opinion writer for the New York Times we're talking about addiction and public policy and when they intersect, what's dangerous about that? We thank her for keeping an eye on this. This is a great topic. Well, you said 90% of established treatment centers use the 12 steps as the foundation for the treatment or as part of their treatment.

Maia Szalavitz 
As far as we can tell, again, this is really difficult to know, I know that it was pretty much 100% in 1988. But you know, there certainly has been progressed towards bringing other things into treatment and towards decentering 12 Steps. I just don't know how much progress there's been because it's really not studied well.

Steve Martorano 
Well, let me sort of just be a devil's advocate here. On some level, it seems to me a lot of these treatment facilities -- very good ones, as a matter of fact, will have in their literature, or information, you derived from them, the 12 steps they mentioned that you know, the 12 steps are part of what we do. But at some point, it seems like that's like a failsafe for them. If we don't do that, in our literature, presenting it to a potential client. It's going to sound as though we have repudiated it as something...

Maia Szalavitz 
I don't think that's the case. Well, first of all, there are many, many, many customers who want something different and who have been through twenty 12 Step rehabs. And so there's that, you know, you can get that for free outside of treatment. Why do you need to be in a place where they're going to teach you exactly what you can learn by like not drinking and going to a meeting?

Steve Martorano 
Are there examples of people who go to a treatment facility that may have 12 steps as part of its, you know, catalog of techniques...

Maia Szalavitz 
I have no issue with it being part of its catalog of techniques. I have an issue with people being told the only alternative to accept the 12 steps is jail institutions and death, which they are commonly told. I have a problem with people being taught that you know, you must hit bottom, and you have to admit powerlessness and you have to say on my end, I'm an addict. And all of these things that we know from research is not are not true. Some people find it beneficial. But to say that this is a universal truth about addiction and the only way you're going to recover is to surrender to this universal truth and to God. I'm just harmful. I think, again, what you should have in rehab is cognitive behavioral therapy, dialectical behavior therapy, motivational enhancement therapy, you know, exercise treatment like stuff that we know works that don't have any of these problems. Like the thing...the active ingredient in what works in the 12 steps seems even not to be the steps. Now some people, it could be the steps, but for the vast majority of people, if they go to any support group where there are other people in recovery that can help them, that seems to work equally well,

Steve Martorano 
how do you respond to the counterargument that the 12 steps are not a treatment?

Maia Szalavitz 
That's why we shouldn't pay for them

Steve Martorano 
I mean, they say it's not a treatment. It's a fellowship, it's a support group.

Maia Szalavitz 
That's exactly what it should be.

Steve Martorano 
I know. But when you go to a treatment facility, they offer, as you said, all those other modalities to treat...

Maia Szalavitz 
What they often don't. Like, they often tell you the buzzwords, and then you get the same old 12 steps.

Steve Martorano 
So you wouldn't object to a situation where 12 sets were part of the program. But if you could, if you signed up to go and get treatment there and said, but by the way, I don't want anything to do with the 12 steps, what else can you do for me...

Maia Szalavitz 
I have no problem if you can genuinely opt-out. The thing is that the programs that center their teaching on it, that is not the case. You might be able to go to a smart meeting rather than an AA meeting on your evening off. But you will be taught the ideas of 12 Steps throughout the programming of the program. And so I believe that again, people should be introduced to 12 steps in the sense that, like, this is a free available support group that helps a lot of people. They should just not be told this is the one true way. And if you don't do this, you're not going to recover.

Steve Martorano 
If a facility offered 12 steps as a completely voluntary part of treatment. There are 12-step meetings going on over here on Tuesdays, Thursdays, and Fridays. You're welcome to join if you want to that would be okay. Right?

Maia Szalavitz 
Yeah, I would have no problem with that. And I also would have no problem with a sort of 12-Step 101. For people who are interested, I do think that again like a lot of people are put off by the God stuff are put off by a lot of the things that they've heard about 12 Step. But many of them actually find that if they go they find something beneficial. Give people an introduction to this. Tell them the most important slogan is to take what you like and leave the rest. But don't create a situation where this is the best or the only, one and where you are because still in a lot of treatment centers. If you don't want to do the steps, you're in denial, you're resistant, and you're not treating and compliant. And that's just not okay.

Steve Martorano 
Now, I've spoken to a lot of people who swear by the 12 steps, and almost universally when asked if they believe it's the only way. They say well for me, but not for everyone. They fully acknowledge it worked for them.

Maia Szalavitz 
Like, I don't hear from those...well, that's not fair. I do hear from those people. I get nice emails from those people. I get nasty emails from the ones who are like you are the devil who...

Steve Martorano  
Yeah, yeah. Well, I remember the first time I ran into the notion of a "dry drunk," I was taken aback. This is I don't know whether it's a term that came from. And that's where they say to you, someone who is in treatment and a firm believer in the 12 steps. Well, if you stop abusing, literally stop...you stopped using but you haven't gone through the steps. You're not really cured, you're not really better, you're a dry drunk and that's the sort of argument that stops me in my tracks.

Maia Szalavitz 
That's not okay, like what's really, you know, there's this whole one true way ism that is sort of cooked into some of it

Steve Martorano 
Well about a lot of things, you know...

Maia Szalavitz 
People are extreme about CrossFit or something, you know? But the thing here is that, you know, you don't have hospitals inducting people into the ideology of CrossFit.

Steve Martorano 
Yeah. No one proselytizers for that sort of stuff. They just tell you it's the greatest thing in the world. You're dope for not doing it. I get that. There's always been something kind and I say this...I said this. As you know, the interest of full disclosure, this program is underwritten by a treatment facility, Retreat Behavioral Health, they do mental health as well, but their basis is substance abuse there...have been...done business with...this is not an infomercial for them. We don't mention that it's the greatest place in the world. It's a fine place, but I've been around them a long time now. And I have seen a change in attitude in the last 10 years, about what works. What works now? The 12 steps are part of it. It's there. What as someone who keeps an eye on the intersection of treatment and public policy, can you see a potential problem with someone being mandated by the courts to go into a program that uses MAC...medicine, you know, drugs to fight drug addiction? That's because that's growing...

Maia Szalavitz  
I mean, let's be real. The only thing that cuts the death rate from opioid use disorder by 50% or more is methadone.

Steve Martorano 
Right? How do you feel about being someone mandated by the state people?

Maia Szalavitz 
I don't think people should be mandated onto medication, if somebody commits a serious crime, and they have an addiction, and they conduct they committed the crime kind of under the influence of the addiction? I think it's perfectly fair for a judge to mandate treatment for that. But they should mandate treatment as you know, you don't go to a mental health court and they say you can have Risperdal but you can't have Haloperidol like they recognize that the doctor should be deciding what the treatment is in consultation with the patient. And that's all I'm asking for with addiction treatment. Like I think it's okay to mandate treatment as part of a sentence. But I don't think it's okay to mandate you must be on methadone, you must be on rebrand morphine, you must be in 12 steps it's more like, you have to mandate that people seek evidence-based care as best you understand it. And you know, because I don't think it's fair to mandate people to, like, you know, go to church every Sunday or something. If we're going to say addictions to disease, if we're going to believe that addiction is a medical problem, if we're going to believe that this is an issue of public health, then we can't have a double standard and also say it's a moral thing that you have to take a moral inventory for. And that it's the only thing in medicine where praying is considered mainstream treatment.

Steve Martorano 
So I want to probably wrap this up here. It's a topic we go on, and a lot of that's very important. And these are provocative questions. I know that I've had them as well. And I've talked to others who feel the same way that they are looking for something. Tina Turner had a big hit song a few years ago. What's Love Got to do with it? If this were a song we were talking about, it might be What's God Got to Do With It? I really, again, if God works, God works, right?

Maia Szalavitz 
Yes, exactly. If that works for you, it's absolutely I just, I don't hate the 12 steps, I have nothing against 12 Step programs, I think they are fabulous, self help, fabulous support. It's just they are not treated, and we shouldn't pay for them as treatment, and we shouldn't pay for their ideas to be taught as the one true way. That should not be controversial. Because in fact, the eighth tradition, it says that people shouldn't get paid for doing 12 Step work. In other words, they shouldn't get paid for teaching other people about the steps. That is a spiritual thing that people should do for free as part of their own recovery. And so they're almost all of this treatment is a massive violation of AA's traditions.

Steve Martorano 
Well, there can be some confusion about people who are fervent believers in the 12 steps and cult-like behavior...

Maia Szalavitz 
No, that's not what I'm talking about. I'm just talking about people who are counselors who are at rehab, where they basically teach the 12 steps as their job.

Steve Martorano 
Yeah, I know, I you know what, and I hear you. And again, you've covered this for a very long time. I've been doing these interviews and talking to professionals in the field and people in long-term recovery for over a decade now. And I can see a change, I can see people's minds opening up. I mean, there's not been a repudiation of the 12 steps, because it's, as you say, works for people it works for, but there are there's a changing attitude about, as you say, this is a medical problem, not a criminal justice problem. We tried to lock people up and solve the problem that didn't work. Let's treat it like a public health issue. So there are a lot of attitudes that are changing. And I think it's worth our time to take a look at something like AA which is the 600-pound gorilla. Sometimes when you think about these things, and ask the right questions about, you know, is this going to help me, and should I pay for it, and what happens when a judge says you got to do it? So we appreciate you for your work there and your time today. Maia Szalzvitz - her op-ed pieces show up all over the place, but notably in the New York Times, and her books are available where books are...great books -- The Unbroken Brain is amazing. I mean, because this is what we're talking about a new way to look at a very old problem of addiction. Maia, thanks so much.

Maia Szalavitz 
Thank you so much for having me.

Steve Martorano 
Pleasure. And we...we did this before your heater repair guy showed up and interrupted us.

Maia Szalavitz 
This is true. I still have no idea what time they're coming, but...

Steve Martorano 
It'll be two hours after they said they'd be there, so we're predictive of that. Thank you, guys, for your time as well. Don't forget to look for us wherever you find podcasts. And when you do, please subscribe. Please like. Do the whole thing. Will look for you next time on the Behavior Corner. Thanks so much.

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