Addictions have been with us ever since men discovered that grapes made a really good mind numbing and tasty liquid, and that certain mushrooms seemed to cause everything to appear a little more vivid. While our collective intelligence as mankind has not changed over the time we’ve been on earth, our ways of getting hooked on something has. After getting hooked on things, some of us decide to try to get unhooked, and over the millennia, particularly the last 100 or so years, some myths about getting unhooked have developed. This is true for both the addict and addict-treating communities. In this chapter we are going to put down the tasty liquids and delicious mushrooms as we compare the myths and realities of treatment of substance abuse addictions.
Let’s start with the four most important older myths, most of which still linger within the addict community.
- No holds barred, in the face treatments, are best.
- Only ex-addicts ought to counsel addicts through their recovery.
- Interventions are necessary to overwhelm the addict’s denial system.
- Intense, confession based, programs such as AA are a necessary part of treatment.
In the early part of the 21st century we have seen the results of many research programs in the area of substance abuse which tend to show that the four myths don’t hold up in the face of clinical data.
Over the last few years a great deal of effort has been put into investigating newer, quicker and more proficient ways of dealing with substance abuse in individuals. This has been primarily driven by the increasing problem of substance abuse in our culture, the secrecy of traditional programs, such as AA or NA, where outcomes are not clinically evaluated, and the desire to cut treatment costs. Some remarkable myth-busting realities have been discovered.
There have been two major research reviews performed in this area within the last 12 years that bring into the light newer, reality based, truths about treating alcoholics and drug abusers. The first review was done by Rudolph Moos of the Department of Veteran Affairs in conjunction with Stanford University in 2003. The second was carried out by Nathan, McCrady, Haaga and Lebow in 2006. Lebow is our book author. Here are the nine major findings of these reviews:
- The core processes of change for overcoming substance abuse disorders are the same whether the addicts participate in psychotherapy, self-help programs or recover without treatment.
For each form of recovery, the process is essentially this; the building of hope for change, gaining understanding of the harmful nature of their addiction and learning how to control addiction behaviors to achieve a better life.
On a personal note, it could be that first point, hope, that is the essential difference between faith based recovery programs and secular programs.
- Not only are the processes of change the same across groups, so are the stages of change.
Prochaska’s stages of change are; Precontemplation, Contemplation, Preparation, Action and Maintenance. The reviews found that the addicts who got through recovery and changed all went through the same stages. In Precontemplation they typically didn’t recognize their problem, deep denial is present. In Contemplation, the addicts recognize the problem but aren’t emotionally ready to change. In Preparation, addicts start to get ready to work on the problem. In Action, addicts enter what we call recovery, and start to act to stop the drinking or drugging. In Maintenance, the last stage, the addicts work hard to stay off the substance they were addicted to.
Often we see addicts bouncing backwards and forwards between stages, particularly Preparation and Action. This prevarication can be thought of as keeping a foot in both camps, the addiction and sobriety.
It was also found that motivation was an important factor in moving through the stages. Whether it was external, such as threats from family or court ordered therapy, or internal such as fear of losses, motivation often provided the extra something needed to push the addict along.
- Intense treatment of short duration is less successful than treatment that extends over time with little interruption.
In a study by the VA of 20,000 patients it was discovered that longer term and consistent treatments were more effective than short term programs. The most important conclusion of this study was that a program such as AA, which keeps the addict involved for years, was the most successful in maintaining sobriety.
- Therapy relationship factors are crucial in treating substance abuse.
Research strongly suggests that the therapeutic relationship between client and therapist, or their group, is highly indicative of success. Therapeutic alliances provide the best results. Poor alliances usually lead to failure or partial success.
- Contrary to stereotypes, high levels of confrontation seldom result in better treatment outcomes.
Surprise surprise! Programs that are confrontational in nature result in argumentative responses in patients, whereas interventions that provide listening and restructuring comments resulted in positive responses. There is no evidence, none, that intense confrontation has a positive effect on outcomes.
It was also discovered that rapport with therapists resulted in much more long term commitment to getting healthy than when rapport was not present.
High levels of social support were far more effective at getting a person to enter treatment than confrontation. Supportive partners helped the non-drinking and drugging, increased positive communication, improved engagement with outside interests and encouraged professional treatment.
- Social support is critical to overcoming addiction and maintaining change.
The bottom line here is that addicts with high levels of social support were far more likely to achieve change. While therapy can help, it is only a minor influence compared to certain other factors, such as informal help and reliable social resources. These translate to participation in self help groups, for example AA, and new support networks, meaning new friends, because old friends often indulged in the same behaviors that were the problem.
- Engage and work with family members as a first step in the change process when clients are unmotivated or resist entering treatment.
Research shows that if a potential client is resistant to entering a program working with the immediate family is often the most effective way of changing that. The spouse is the single most important person in this regard.
- Therapists with a personal history of overcoming substance abuse are no more effective than those without such a history.
While this is true, it was discovered that therapists who specialized in substance abuse were more effective than therapists that didn’t.
- No one substance abuse treatment was more effective than others.
Of all the major treatment approaches; motivational enhancement, cognitive behavioral and 12 steps programs, none stick out as best. However, effective treatments are all directive and active, provide understanding of the harm of substance abuse, build life’s coping skills and enrich or strengthen significant relationships.
I’m going to put this into some plain words. For substance abuse:
- Short and sweet doesn’t cut it.
- No method is above the rest.
- Confrontations make matters worse.
- Good relationships improve outcomes.
Spiritually Speaking – This whole blog speaks the truth of this scripture for addicts, we sometimes can’t move forward because we return to our own vomit or to wallow again in the mire:
2 Peter 2:22 – What the true proverb says has happened to them: “The dog returns to its own vomit, and the sow, after washing herself, returns to wallow in the mire.” ESV