Unsubstantiated Malarkey Versus Evidence Based Programs that Improve Outcomes
Question:
How many Al-Anon members does it take to screw in a lightbulb?
Answer:
None, they just sit there and watch it screw itself.
Al-Anon in a nutshell.
“Let Go, Let God”
Watch your family members and friends suffer while you do nothing – until you realize that doing nothing is resulting in your loved one’s physical and mental deterioration and impending death.
The Too-Often Bitter Postmortem
For too many parents, there is the bitter, heartsick, recurring postmortem: Why didn’t I try something sooner? Often triggered by news of what actually works for effective addiction treatment, I learned after several chance encounters never to tell these survivors what I do for a living because it inevitably leads to tears.
The tragedy is, of course, that following Al-Anon’s teachings lead to relapses and missed opportunities to pursue effective recovery strategies. Meanwhile, the disease progresses along with attendant negative self-destructive behaviors.
Contingency/Recovery Management Works
For years, treatment centers have known about the highly successful programs for doctors and pilots, where medical boards and airlines are involved in intensive recovery management and oversight for several years.
- Referred to as contingency management, more and more research supports this approach as an effective treatment for addicts and alcoholics.
However, attending Al-Anon, and its message – “Let Go, Let God” – continues to be promoted by family programs, counselors and treatment centers, in spite of the widely available studies documenting models much more successful than doing nothing (i.e., waiting for the light bulb to screw itself).
Behavior Modification for Behavioral Health Disorders (Duh)
Substance dependence and mental health concerns are behavioral health disorders. As such, it is logical to implement behavior modification techniques (e.g., positive reinforcement), while identifying and reducing negative reinforcers, to encourage addicts to change their behavior. Similarly, the habit guru, Charles Duhigg, views addiction as a pleasurable habit gone bad, with recommendations on transitioning to new activities without the drink or the drug.
According to an excerpt from a review by Harvard’s Recovery Research Center on Addiction:
A common hurdle for practitioners and families is successfully engaging youth in treatment so that they stay engaged until treatment completion. Health behavior change research suggests that one way to address this issue is to directly counteract potential barriers …
Parents: No letting go here! Are you getting the message?
Whether you call it contingency management, therapeutic leverage, recovery management — they all require parental involvement. All improve outcomes.
More from a high school parent letter to our local paper:
If it takes a community to raise a child, without doubt, it takes that same community to keep a child off drugs. He is fortunate to have such a community of committed supporters, holding him accountable to staying on a good path.
What is she doing that so many parents are told by Al-Anon and treatment centers not to do, but absolutely should?
- No secrets – Addiction hides in secrecy.
- Multiple accountability sources – Limits the addict crafting different stories for different people.
- Openness about the “path” – Friends and family know the recovery plan.
The very opposite of Al-Anon.
Why Continue to Promote An Unproven, Destructive Philosophy?
“Letting Go” is ossified advice to family members completely unsubstantiated by evidence or research and contrary to best practices. It is responsible for needless suffering for so many alcoholics and addicts. It would be one thing if there was proof that following the Al-Anon philosophy improved recovery rates, but there is none. Anecdotal evidence is just the opposite, and its continued practice is a primary reason why recovery rates are so low.
- One wonders why treatment centers continue to promote this ineffectual approach to recovery.
What are the origins of this advice and supposed theory? And what benefits inure to treatment centers by centering family program curriculum for parents/relatives on the Al-Anon steps and principles?
Two reasons:
- Bill Wilson, AA founder, developed the principles underlying Al-Anon.
- Treatment centers find it very convenient to promote a doctrine that tells family members to ask no questions about treatment.
Both reasons will be addressed in the next two sections.
Bill Wilson’s involvement in developing Al-Anon principles
Bill Wilson wrote the chapter in Alcoholics Anonymous “To Wives,” pretending to be a wife while giving advice to wives!!!
Key messages:
- Never be angry. Patience and good temper are most necessary. (p. 111)
- Never tell him what to do about his drinking. (p. 111)
- Do not set your heart on reforming your husband (p. 111)
- You must be on guard not to embarrass or harm your husband. (p. 115)
- We never, never try to arrange a man’s life so as to shield him from temptation (p. 120)
- God has either removed your husband’s liquor problem or He has not. (p. 120)
What could be more perfect for an addict than to have family members never criticize your drinking, treat you with kindness and to never suffer consequences?
My strong suspicion is Wilson wrote these words because, when drinking, he wanted to keep doing so without consequences and with no accountability after he quit. Some cursory online research indicates that his wife, Lois, was not happy about Bill writing the chapter in the guise of a wife, but she kept quiet to keep the peace. The upshot is that when Lois started the first Al-Anon group, the program content was heavily influenced by Bill and the “To Wives” chapter in Alcoholics Anonymous.
In any event, letting go and hoping God will intervene is a completely ineffective responsive to a deadly disease. The combat slogan “Praise God and Pass the Ammunition” is a much more apt phrase, as we need to combat addiction, not hope it disappears.
- For example, there is a wealth information supporting removal of alcohol from the home during early stages of recovery due to the well-documented research on the power of environmental cues.
But there are still treatment centers not mentioning this topic or, when such questions are raised, saying it does not matter. Continuing to give advice in this vein constitutes malpractice and, as mentioned, is one reason for high relapse rates.
Final quote from Bill (as wife):
Never forget that resentment is a deadly hazard to an alcoholic. We do not mean that you have to agree with your husband whenever there is an honest difference of opinion. Just be careful not to disagree in resentful or critical spirit. (p. 117)
Remind me to reproduce this advice from the expert in ALL CAPS 20-pt. font and post it in multiple locations around the house!!! Thinking about attending Al-Anon? Hold that thought. Once again you have been bamboozled by an alcoholic.
Promoting Al-Anon Enables Treatment Providers to Avoid Accountability
The natural inference or corollary to Letting Go and asking no questions of your substance dependent loved one (LO) is to refrain from directing questions to treatment centers or counselors regarding your LO’s treatment. That would be “controlling,” “interfering in the treatment process,” or one of the many other pejorative comments directed at families or outsiders seeking information on diagnosis, progress or aftercare plans.
As commentators note, treatment centers are welcoming and solicitous towards family when selling the benefits of their programs, but once that credit card is charged or the check written, the door closes. You may have just shelled out $30,000-$50,000, but common questions (see below) are not answered, even in family meetings with the patient present:
- Using history, including substances
- Diagnosis
- Program plan
- Treatment progress
- Factors supporting use
- Post-treatment recommendations
- Relapse plan
As to the last item, given that relapse is the most common outcome of treatment, one would think this would be an important topic. But no, it is similar to He Who Must Not Be Named. If relapse is discussed, it is more likely to happen. If this sounds like voodoo treatment, it is, akin to Letting Go and Letting God.
- Do nothing. Say nothing. See nothing. The treatment center mantra for families.
You can’t imagine the pushback we get from many treatment centers when we obtain patient releases and start asking questions or giving input on programming and aftercare.
Delayed Treatment
The crucial bottom line from the continued promotion and prevalence of the Al-Anon philosophy in the addiction/recovery community is delayed treatment. Delayed treatment means substance dependence metastasizes from mild/moderate to severe and chronic (cancer analogy deliberate), increasing the odds of disability and death. For those of us who are conflict avoidant, Al-Anon provides the rationale for doing nothing and waiting for our family member with the problem – whether it be an addiction, eating disorder or mental health concern – to seek help. Inevitably, there will be a reckoning.
- Postponing is NOT a successful strategy – it is NO strategy.
Assuming it is not an emergency, it’s better to wait while you find qualified, professional help as part of the process of addressing the problem. One goal of this counseling process is for family members to form on a consensus on moving forward. Otherwise, your LO will exploit the divisions to avoid treatment, a topic for further elaboration in my next piece on why Al-Anon needs to be relegated to the graveyard of failed recovery theories.