Our
Rationale
The
scientific foundation of our approach
Although
AA and other 12-Step groups dominate US addiction treatment (93%
of all treatment programs), federally funded research reveals that
most individuals referred to such groups refuse to attend. Based
on AA's own data, most who attend do not follow through or benefit
substantially.
Even though
the dominant treatment approach serves only a minority of
individuals, alternative approaches are difficult to find, partly
because AA has become so entrenched in US culture that many are
afraid to suggest publicly that AA isn't for everyone. Some of the
reasons for dropping out of 12-step groups include difficulty
accepting the need for a higher power, belief in a different kind
of higher power, not viewing addiction as a lifelong disease, not
wanting to attend groups, or not viewing oneself as an
"alcoholic" or "addict."
Research
shows that the severity of addictive behavior ranges from mild to
severe. The majority of individuals affected have problems in the
mild to moderate range. Many of these individuals would benefit
from moderation programs. Yet 99% of all treatment programs are
based on abstinence as the only acceptable goal. As a result
everyone is categorized and treated in the same one-size-fits-all
system.
There are
many scientifically supported treatment techniques which view
addiction as a learned behavior, one which can be changed by the
development of healthy habits. If you are interested in reading
more about what has been discovered about alcoholism treatment, an
excellent scientific overview is provided by:
The
Handbook of Alcoholism Treatment Approaches:
Effective Alternatives (3rd
edition)
Edited by Hester, R. &
Miller, W.
Boston: Allyn & Bacon, 2002
The authors
reviewed all 363 randomized controlled clinical trials of alcohol
treatment available in the scientific literature up to that time.
The randomized controlled clinical trial is the highest form of
scientific evidence about treatment effectiveness. The authors
conclude that:
"the
negative correlation between scientific evidence and
treatment-as-usual remains striking, and could hardly be larger if
one intentionally constructed treatment programs from those
approaches with the least evidence of efficacy (p. 41)."
In other
words, traditional US treatment is easy to find, but not very
effective. What's hard to find is effective treatment. However,
you can relax, you have already found us!
The
National Institute on Drug Abuse (NIDA) of the National Institutes
of Health wrote a similar document focused on substance use other
than alcohol. This document summarizes the principles of effective
treatment. Among these principles are: No single treatment is
appropriate for everyone; Effective treatment takes into account a
person's multiple needs, not just drug use; and Counseling and
other behavioral therapies are critical components of success.
Our
perspective on 12-step based (traditional) treatment
We
support anyone's decision to attend 12-step based addiction
treatment, or 12 step groups. 12-step works quite well for some
individuals. We remind our own clients that the 12-step approach
remains an option for them if they feel they are not making
sufficient progress with us.
We believe
that all individuals seeking addiction help should be informed
about the range of treatment options and support groups available
to them, and allowed to choose for themselves the approach that
seems best. We strenuously object to the typical practice of
referring clients only to 12-step groups or treatment.
Should you
be in conversation with a 12-step extremist (someone who believes
that 12-step is the only way someone can recover and "anyone
who says otherwise is killing people"), you might raise the
following two points.
First, if
by disease we mean someone can't control addictive behavior, then
addiction is not a disease. One can choose to stop anytime it is
important enough. Put a gun to the "addict's" head (or
to a loved one), and see if they continue. The disease perspective
confuses internal experience, such as cravings, which indeed one
cannot control, and voluntary behavior like acting on the craving,
which is controlled anytime it is important enough. Any person
with addictive behavior has numerous examples of self-control (of
some degree), but they tend to overlook them if they have a
disease perspective. Perhaps even more importantly, the disease
perspective seems to explain why people keep using, but it doesn't
explain why they stop! How do they stop? They make a decision to
stop. If we could only deal with cancer that way!
Second, no
US citizen should be required to attend 12-step groups, because
such a requirement would violate his or her religious freedom.
12-step is fundamentally a "spiritual approach." As
such, we hope no one has an argument with it. A spiritual approach
is distinct from viewing addiction as a disease, which is a
scientific question. According to the US Constitution's First
Amendment ("Congress shall make no law respecting an
establishment of religion, or prohibiting the free exercise
thereof"), US citizens are free to attend 12-step meetings.
Similarly, they should be free not to attend them, if they object
to their religious content. Fortunately, since 1996, appeals court
decisions in multiple states have recognized the freedom of
citizens not to be ordered into 12-step groups by the government
or its representatives. We hope that these decisions will be
extended throughout the US.
For a
review of this issue from the Duke
Law Journal,
February, 1998 (Vol. 47, # 4, pg. 785)
An
excellent book on this issue, for which Dr. Horvath wrote the
Introduction, is Resisting
12-step Coercion: How to Fight Forced Participation in AA, NA, or
12-Step Treatment,
by Peele, Bufe, and Brodsky:
Click
here for a summary of the most recent court decisions on this
issue
Unfortunately,
the 12-step approach is so deeply embedded in the addiction
treatment community that there is tremendous resistance to
alternatives. This resistance doesn't seem to be a fundamental
part of the 12-step philosophy, but to have developed over time.
Much of the traditional treatment community engages in willful
ignorance about alternatives, or deliberately suppresses
information about them. For example, if you click on
http://www.niaaa.nih.gov/Resources/RelatedWebsites
you will
see that no alternative support groups are listed. This is despite
repeated attempts on our part to get NIAAA to add them. One would
think the federal government would be more responsible. If they
change their site, let us know. For the moment, we have given up!
Fortunately,
two other components of the federal government are more sensible.
1) SAMHSA
and the VA sponsored a work group on addiction support groups,
which met in November, 2001, and produced the following document.
Dr. Horvath was a member of the work group and a co-signer of the
document. Among its conclusions is that:
"clinicians
should recognize and communicate to patients that many individuals
recover through AA, but others recover through self-help groups
other than AA, or, without attending any self-help group at
all"
(pg. 2 of Executive Summary)
http://www.chce.research.med.va.gov/chce/pdfs/VAsma_feb1103.pdf
2) NIDA
lists SMART Recovery, in FAQ #9, at
http://www.drugabuse.gov/PODAT/PODAT6.html
Because of
the resistance to alternatives, most of our clients come from
referrals from former clients, our ads, our website, and referrals
from other psychologists, who tend to be more scientific and
open-minded than traditional addiction treatment providers.
Despite the resistance to alternatives in others, we continue to
make sure all of our clients are aware of the potential value of
12-step groups and 12-step based treatment.
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