Much has been (and is still being) said about the – apparently true – allegations on the Smoking Gun Web site to the effect that many of the details of James Frey’s compelling, and best-selling, memoirs A Million Little Pieces and My Friend Leonard are not true. In particular, Frey seems to have grossly exaggerated the bad-boy image he creates of himself in the first book especially. His supposed brawl with police in Ohio, resulting in numerous felony charges and a 3-year prison sentence which was miraculously busted down to 3 months after intervention by his colorful rehab friends – a mobster and a federal judge – appears to have been nothing more than a simple, completely non-violent bust for “open container” and driving without a license. (The Smoking Gun canvassed every county in Ohio, finding no police or court records on Frey anywhere except for this one minor incident; the timeline of the book makes it almost impossible that any other such incident could have occurred. He did no time for that incident, and spent a total of less than 5 hours in jail before making bail.) This gap in the facts is particularly problematic because it was his reported incarceration for that incident, after completing rehab, that precipitated the tragedy, and his resulting spiral into depression, that motivates much of the second book; if the 3-month prison term never happened, how much that depends on it could have happened? There are many similar missing pieces: Frey reportedly admits adopting the heartbreaking story of the train-crash death of two teenage friends and putting himself – falsely – into the scene for dramatic effect; the friends’ families are reportedly shocked and furious. The entire story of his rehab girlfriend Lilly – the emotional heart of both books – is suspect, both because of specific factual gaps such as noted above and because the entire story becomes less plausible as these gaps are revealed. And it becomes even more suspicious – a point critics had noted as soon as the book was published – that so much of the story seems clicheic, over-dramatized, or implausible even before the facts are checked: the fallen-angel girlfriend who redeems him with her love; the livin’-large mobster buddy and his Cadillacs, flash cash, tough-guy talk, and vaguely menacing meatball associates; the poor nerdy guy who achieves moral heroism with his emotional honesty; the jaded, take-no-shit drug counselor who grudgingly respects the protagonist’s insistence on walking his own path; and Frey’s constant, self-reported encounters with authorities that inevitably end with him setting some impossible record (level of alcohol intoxication; amount of cocaine ingested; amount of pain withstood [four fillings and a root canal all at once with no anaesthetic]; ability to refuse drugs and alcohol once he sets his mind to it); and so on. Frey himself is now crawfishing awkwardly, putting up a dismissive front on his Web site (“let the haters hate, let the doubters doubt, I stand by my book, and my life”) but making excuses in interviews and simultaneously hinting evasively that the accusations might really be true. In the end, it seems apparent that Frey grossly dramatized his experiences, while insisting his was a true story and publishing it as a memoir, not a dramatization or a novel. (He reportedly offered an even-more-dramatized version of the text to many publishers as a work of fiction, before the supposedly-factual version of it was accepted as a memoir.)

This would be disappointing in itself, but it has unfortunate healthcare implications.

One of the major themes of Frey’s books is self-reliance. He contemptuously dismisses 12-step programs because of their emphasis on a “higher power”, which he does not believe in, and because they insist on both pathologizing bad behavior and creating a dependency on the program itself – with their doctrine of “recovering” (never “recovered”) and their demand of surrender to the Higher Power, they are a form of self-imprisonment. Frey – an atheist – insists on beating his addictions through willpower alone. He is confident that by simply deciding not to be a drunk or an addict anymore he can completely overcome his desire for alcohol and drugs. He breaks away from the rehab facility on a desperate after-dark run to rescue Lilly from a crack house; the tough, experienced drug counselor refuses to enter it with him because he is too afraid of “it” (drugs), and after Frey pulls Lilly away from a crack pimp and tears the drugs and pipe out of her hands, then carries her out of the building, the counselor asks “Were you close to it?” and later confesses he cannot believe that Frey actually touched a crack vial without falling to his knees that very moment to smoke it up. (“That is not supposed to be possible.”) Frey tests himself: immediately after leaving rehab he drives directly to a bar, orders $40 worth of whiskey in a single glass, and sits over it at length, breathing the vapors and bending nearer and nearer until his nose touches the liquid and he is consumed by desire to drink – then straightens up, pushes it away, and never takes a drink in the 10 years before he writes his book. His rehab counselors implore him not to do this – they are certain he will fall off the wagon within hours and destroy his precarious gains, certain that the 12-steps are the only way anyone can ever beat an addiction; they are awestricken when he goes cold-turkey on his own terms. Later Frey takes a job as a bar bouncer – like Sam from “Cheers”, being an ex-lush is no barrier to his hanging around drinkers all day.

This emphasis on willpower, and the rejection of 12-step ideology, is the most telling part of the two books from a health-policy perspective. And it is tempting to imagine now, after all the other rvelations, that Frey has overstated his case here as well as in other ways. That is very disappointing, because, to the extent that these incidents and their outcomes are fabricated, they risk inveigling other 12-step doubters into reckless behavior, or at least sub-optimal approaches to therapy. They also undermine the medical model of addition. Frey insists on a (very ironic) brutal honesty, constantly repeating “I am an Alcoholic, a Drug Addict, and a Criminal” (with capital letters) and regards an addiction “diagnosis” as a prevarication – addiction is merely the addict’s own bad choices gone out of control. (But note that his own “honesty” about his addiction appears to be grossly exaggerated, and many of his factual statements are apparently quite false.) One imagines that, post-Frey, there will be legions of freshly-rehabbed addicts running around, promising themselves they’ll quit “any day now” and playing chicken with “just a taste” of alcohol or drugs (“I can quit any time I want!”) – and potential 12-steppers who are taught that that program is a sham and they should try to make it on their own. These messages – far from explicit, but also unmistakable – backed by heroic but apparently false tales of Frey’s displays of willpower, feed the real objections there are to be made to 12-step programs with dramatic but apparently false examples. To the extent that people read Frey as an object lesson and not just a self-aggrandizing writer, he is playing with their health and their lives.

A problem with this general subject is that both the 12-step programs and their alternatives are surrounded in hype. Twelve-steppers claim that their programs are the only effective treatments for addictive behavior. The counselors in Frey’s book repeatedly state that no one succeeds in beating addiction without the 12 steps. (This serves to set up another unique James Frey superlative: the only man to beat addiction without the 12 steps. “He can even stick his nose in whiskey and not drink!”) But we know this isn’t the case, from the existence of non-12-step programs and the many people who have solved their abuse problems without formal therapy. In setting up 12-step as the be-all of addiction therapy, Frey exaggerates his triumph in succeeding without it – but to do so must pull out all the stops in “exposing” it as fraudulent and creepy.

In fact, we don’t know what makes addiction happen, and we don’t know how 12-step programs serve to overcome it. There are many common-sense elements to the programs (admit you have a problem, take one step at a time, create a network of supporters, maintain frequent reinforcement of your commitment through meetings, ceremonies, and other overt acts, etc.); there are certainly many questionable ones (admit you are “powerless”, invoke a “Higher Power”); and there are elements that raise real questions about the pathology of addiction and whether the AA model perceives it correctly (you can never be cured, you can never indulge again in the slightest way, you must atone for past sins [a good idea, but what does it have to do with addiction per se?], etc.). It is just as common-sensical to imagine that a different program, incorporating a more realistic model of addiction plus some of the more practical of the 12 steps, would be at least as effective as AA, and likely more so. The existence of atheistic recovery programs based on a modified AA model also points to this possibility.

At the same time, it is also true that AA and its like programs have done tremendous good for the many who found they worked for them personally. It’s hardly a new thing that a successful therapy can be based on a flawed clinical model – and the variations in personality, temperament, and circumstance between patients make psychology-based programs of any kind very much a hit-or-miss proposition. That 12-step programs work at all may be reason enough to retain them, even if they don’t work for everybody. In setting these programs up as almost sinister, Frey may be driving people away from an effective – if theoretically dubious – empirical therapy that is proven helpful in some cases.

What worries me about the Frey fiasco is that he verges over from telling an engaging and dramatic story to offering “insights” into addiction and recovery. (The first book is filled with diatribes about self-indulgent addicts’ victimization cant, Frey insisting angrily that the only thing wrong with him – and by extension other addicts – is his bad choices and their inevitable consequences. Necessarily, then, he becomes not only the most willful addict in history but the only honest one as well.) These insights are drawn from his personal “experiences” – experiences that seem to be not only dramatized but grossly misrepresented. But the book’s impact has spread far wider than any corrective clarifications will do, and to some extent that impact is almost certain to include an influence on readers’ perceptions of addiction and recovery, and their decisionmaking when faced with similar problems in their own lives.

The larger point, perhaps, is the pop-culturization of medical decisionmaking in general. We have ads for prescription drugs aimed at non-technical consumers, extensive – and badly-informed – debates over medical and research issues taking place in sound-bite media and partisan venues, and an increasing avalanche of plausible but delusional fad diets, pop therapies, and vaguely religious or mystical health teachings flooding an amazingly credulous marketplace. There seems to be no sense at all among the purveyors of this dramatized crap that they have any responsibility to the consumers whose choices, health, and lives they are toying with. It is very frightening that many, perhaps millions of people’s understanding of addiction has been grossly perverted by a fraudulent book that started its life as an overt work of fiction. It is more frightening that this isn’t the worst problem of this kind to be seen in the marketplace today.