Beyond 12 Steps, MSN 2008

By Maia Szalavitz for MSN Health & Fitness
MSN Health & Fitness Exclusive
Spring, 2008

click here to see Dr. Horvath’s

Although addiction and alcoholism treatment research has advanced tremendously since Alcoholics Anonymous was founded in 1935, many people do not know that equally effective alternatives to 12-step programs exist-nor do they know how to find them.  In popular culture, AA is often portrayed as the only way.

Worse, while reality TV spotlights tough family “interventions” as a way of getting people to enter treatment and often shows rehab as a “boot camp” or exercise in humiliation, research finds that both these approaches have significant risks, and other less risky tactics have equivalent or superior benefits.

So, how can you find evidence-based addiction and alcoholism treatment for yourself or a loved one instead of-or as an addition to-12-step approaches?

Here are five “dos” and five “don’ts” that can guide you to the best treatment.

1.  Do start your search for treatment with a full psychological or psychiatric evaluation from an M.D. psychiatrist or Ph.D. psychologist.

At least 50 percent of people with alcohol or other drug addictions have an additional mental illness, such as depression, anxiety, attention-deficit disorder or bipolar disorder. But unfortunately, many addiction counselors do not have the expertise to diagnose these disorders-let alone treat them.

“If you go to a barber, you’re going to get a haircut,” says William Miller, Ph.D., emeritus professor of psychology and psychiatry at the University of New Mexico, a leading expert on addiction treatment. “If you go to a substance abuse treatment center you’ll get substance abuse treatment, but they may not be well-equipped to deal with the other things that come along with it.”

Adds Alan Marlatt, Ph.D., Professor and Director of the Addictive Behaviors Research Center at the University of Washington: “If you get a proper diagnosis and evaluation, someone may be able to offer integrated treatment to deal with both without having to be shunted back and forth between substance abuse and mental health centers.”

Since people with mental illness often self-medicate with addictive drugs, treating those conditions can be critical to starting and sustaining recovery.  However, in many cases, that isn’t enough:  Once someone has developed an addiction, even if the problem that the person was trying to medicate away has been solved, the addiction may continue.

Avoid the chicken-and-egg debate-treat both simultaneously for the best results; also, look for providers who specialize in “dual diagnosis.”

2. Do look for therapists who use “empirically supported” or “evidence-based” treatments like cognitive behavioral therapy or motivational enhancement therapy.

Although many people believe that treatments must be proven to work before they can be used in practice, this is not the case for talk therapies like those used for addictions.  In many states, an addiction counselor doesn’t even need a high school degree-and some inpatient programs for teens are completely unregulated in terms of staff qualifications and basic health and safety requirements.

Fortunately, there are several talk therapies that have been proven to help with addiction.  These include cognitive behavioral therapy, motivational enhancement therapy (sometimes called motivational interviewing) and 12-step facilitation for those who are involved in 12 -step programs.

Cognitive behavioral therapy involves understanding and changing the thinking patterns that produce urges to use psychoactive substances as well as altering habits that drive the addiction.  Motivational interviewing helps people increase their ability to change their addictive behavior, by helping them achieve the goals they personally consider important.  12-step facilitation introduces people to 12-step programs like AA and Narcotics Anonymous and helps them affiliate with these support groups.

Matters are complicated by the fact that some people who claim to use specific techniques know all the right buzzwords but haven’t been trained in the therapy, or don’t apply it correctly.  Ask about specific training; ideally see a practitioner with a master’s degree or higher and for teens, look for such qualifications in those who treat them day-to-day at any program.

3. Do make sure you feel safe and understood by the therapist or treatment approach you choose.

While evidence-based techniques are valuable, their effectiveness relies on the listening skills and empathy of therapists who use them.  In fact, therapists’ abilities in these areas are directly linked to good outcomes.

“You should feel respected and feel that the person is interested in understanding your perspective, not imposing their reality on you,” Miller says. While many people feel that an ex-addict or alcoholic counselor will be more likely to empathize, in fact, the counselor’s own experience is less relevant than her actual skills in relating to clients, he adds:  “’Is this
a kind person?’ ‘Did I come away with skills I didn’t have before?’ is a good litmus test.”

4. Do get as much social support as possible-and don’t limit your search to traditional support groups.

The research is clear that social support for a healthy lifestyle is an important part of recovery.  But this doesn’t have to come from 12-step groups-it can come from your friends, family, even from a hobby, church group or other interest group that opposes-or simply doesn’t involve-drinking or other drug use.  “Look for people who are rooting for you to get free,” Miller says. “If you don’t have them in your natural
network, it’s important to find them.”

SMART Recovery is one of the largest alternative recovery support groups. Says Tom Horvath, president of SMART, “We’re pushing 400 groups worldwide, with some in correctional facilities and we have a strong presence online.” SMART’s website had about 16,000 unique visitors in March.  “It’s a practical, pragmatic, problem-solving approach,” says Horvath, “The tools we incorporate into our meetings have been studied-it’s as close to evidence-based as we can get.”

Other recovery support groups include Women for Sobriety, LifeRing Recovery and, for people with drinking problems who want to moderate but not quit, Moderation Management.  Many churches, temples and mosques also have religion-specific recovery groups.

5. Do consider the use of anti-addiction medications.

Some anti-addiction medications offer considerable help to those trying to kick drugs, when used in conjunction with other support. For alcohol, naltrexone (reVia) and Vivitrol (a longer acting naltrexone,
only needed once a month) help reduce craving by blocking opioid receptors and reducing the “high” from drinking.

Acamprosate (Campral) works by calming the brain’s glutamate system, which is believed to be over-active during alcohol withdrawal and thereafter (though some studies failed to find a benefit) and disulfiram (Antabuse) produces an extremely unpleasant reaction if alcohol is consumed.

Interestingly, Antabuse also seems to reduce cocaine use-and not just by making it impossible for people to drink while trying to come down or by causing a bad reaction to cocaine.  “Something’s going on,” says Frank Vocci, Ph.D., director of the Division of Pharmacotherapy for the National Institute on Drug Abuse. “We’re not quite sure what.”

Two other medications that are approved by the U.S. Food and Drug Administration for other conditions, topiramate (Topamax) and ondansetron (Zotran), have also been found to help alcoholics quit.  “There’s sufficient evidence for physicians to feel comfortable prescribing them,” says Vocci.

For heroin or painkiller addiction, buprenorphine (Suboxone, Subutex) can be used either for detox or for maintenance and can be prescribed by doctors, not just specialized clinics.

Methadone is also useful, especially for those who have used opioids for long periods of time at high doses. Maintenance treatment does not mean that the person is still “high” or “not really in recovery”-neither methadone nor buprenorphine produces ongoing impairment when used as prescribed.

For methamphetamine, new research suggests that for people who use less than 18 times a month, the antidepressant bupropion (Wellbutrin) may help increase abstinence.

6. Don’t accept treatment that is confrontational, humiliating or degrading.

For much of the 20th century, addiction treatment involved humiliating rituals like being “confronted” and having your personality flaws attacked in brutal detail. “There’s no evidence that it’s helpful and there is evidence that it’s harmful,” says Miller, “Don’t buy the line that it’s good for you or the only language your addicted child can understand.  There’s no scientific evidence for it-it’s simply cruelty.”

7. Don’t think a formal “intervention,” in which family members confront the addict about his or her problem, is the only way to help.

Although the reality show “Intervention” presents this as current practice, there are gentler, more productive techniques. Community Reinforcement and Family Therapy has been found to be twice as effective in helping families get loved ones into recovery. A book on how to do it if you can’t find a local therapist who practices it is now available.

Traditional interventions can produce family rifts and are even implicated in some suicides.  “The evidence doesn’t support it,” Marlatt says. “Courtney Love pulled together an intervention on [rock star] Kurt Cobain. A few days later, he committed suicide.”

In contrast, CRAFT offers positive steps to help families attract their loved ones into recovery.  It teaches practical techniques to families which involve helping the addicted member associate negative consequences with substance use and offering hope, rather than fear, to motivate change.

8. Don’t assume inpatient treatment is superior to outpatient treatment.

People tend to believe that more expensive is better-but in fact, research doesn’t find costly inpatient rehab to be superior to outpatient, except for people who are homeless.

“It’s marketed to parents-’Mortgage your house to pay for our treatment to save your kid’s life,’” Miller says. “But ultimately, the kid has to deal with life back in the community. They’ll say, ‘Sure, you need aftercare.’  Well, what is aftercare?  Outpatient treatment!  And then the question is why you need hospitalization to begin with.”

It’s not a sprint, it’s a marathon,” says Horvath, “If you only have a limited amount of money to spend, it’s better to spend over a longer period of time than a shorter one.”

Vocci notes that if people stick with any kind of treatment for 90 days or more, the outcomes are much better.  “We don’t know why, but that does seem to be the case,” he says.

9. Don’t use a facility for “troubled teens” that treats multiple disorders with a one-size-fits-all approach.

Some “boot camps,” “wilderness programs” and “emotional growth boarding schools” are marketed to parents as solutions for addiction problems.  There is no evidence that these are more effective than alternatives which have proven results-and because the regulations on these programs are lax (in some states, non-existent), they can be dangerous.  These programs also claim to treat other disorders like depression and Asperger’s syndrome-but the treatment is not individualized.  “One size does not fit all,” says Marlatt.

10. Don’t give up!

Studies find that smokers-who have what addicts with experience kicking multiple drugs say is the hardest addiction to quit-often try nearly a dozen times before they succeed.  “When someone says, ‘I can’t do it, I’ve relapsed four times,’ I say, keep trying, you’re not even halfway there yet,” says Marlatt.

Persistence is the greatest virtue in recovery,” says Horvath, “If you keep making mistakes but work to understand them, eventually you will run out of mistakes to make.  In SMART, we say, if you slip or relapse, please come talk about it because everyone will learn from it.” 

“We are blessed with a nice range of evidence-based treatments,” says Miller, “If what you are trying isn’t working, try something else.”

Maia Szalavitz is a freelance journalist and senior fellow at media watchdog, stats.org. She is co-author with Bruce D. Perry, MD, PhD, of The Boy Who Was Raised as a Dog and Other Stories from a Child Psychiatrist’s Notebook: What Traumatized Children Can Teach Us About Loss, Love and Healing (Basic, 2007).