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We’ve previously discussed the benefits of at-home treatment for addiction, but what about out patient treatment in general? We’re taking a closer look at the benefits of out patient treatment with the help of the Recovery Research Institute‘s (RRI) research study titled “Buyer beware”: Treatment admissions practices and costs of residential treatment for opioid use disorder. We want consumers and families to have access to safe and effective treatment options and to know how to advocate for themselves and their loved ones. In order to have access to that, you need to know what effective treatment practices are and how to avoid being pressured into a treatment plan that isn’t the right fit. 

We know that in-patient treatment does not reduce the risk of overdose. We also know that continuous use of Methadone or Buprenorphine for at least six months cuts the risk of overdose in half. This is to say that in-patient and out-patient are just as effective for treating opioid addiction. The key is continuous use of an opioid substitute, usually in combination with an active recovery program. 

RRI’s study surveyed nearly 300 treatment centers and found that many admission practices are both deceptive and fail to follow ASAM practice standards, leading to unnecessary and costly in-patient admissions. Only a minority of treatment centers engage in questionable admission practices (this is more common among for-profit treatment centers than non-profit treatment centers), but the number is large enough to warrant educating consumers about these practices so they know what to look out for when they decide to seek help. 

Many parents exhaust their resources on in-patient treatment, believing it will be successful, only to realize later that it would have been better to pay for an effective post-treatment recovery management program. Some in-patient rehabs may cost around $6,000 for a 30-day program. Well-known centers often cost up to $20,000 for a 30-day program. For those requiring 60- or 90-day programs, the total average of costs could range anywhere from $12,000 to $60,000.²  RRI’s report provides further support for redirecting family attention from in-patient treatment to a combination of detox/out-patient treatment, medication and ongoing recovery plan oversight as a successful model for recovery from opioid dependence (as well as other substances).

The term treatment used in the report refers to traditional in-patient treatment, not to a short stay in a detox center. In my view, in-patient/hospitalization is good for detoxing from opioids, with successful recovery then dependent on taking opioid substitute medications for at least six months. Outcomes improve if users are also involved in a supervised active recovery management program, in addition to taking medication. But the bottom line is that in-patient treatment does not improve outcomes for opioid users unless combined with on-going medication for six plus months. Unfortunately, many parents are very aware of this fact only after paying for multiple treatments and enduring relapses when there was ineffective follow up to assure medication compliance. While the report uses the phrase, six plus months, our experience supports monitoring and oversight for at least three years.

Costs aside, our reasons for being wary of in-patient treatment centers are abundant… 

1. Residential (In-patient) Treatment DOES NOT Reduce Risk of Overdose – When examining first treatment received after an opioid use disorder diagnosis, receipt of agonist medications such as buprenorphine for 6 or more months is associated with reduced overdoes risk, but residential treatment is not associated with this reduced overdose risk.¹ Note that only a minority of treatment centers in the survey offered agonist medications (Methadone and Buprenorphine), so ask whether these medications are available when talking to in-take personnel at a treatment center.
2. The Substantial Majority of Opioid Users do not Receive or Require Residential Treatment – …the substantial majority of people who resolve a substance use problem do not receive, nor require, residential treatment – which can be both costly and may unnecessarily remove people from their homes and work situations. Many respond well to less expensive outpatient level care…¹ The key piece to understand here is that when seeking help, families are often directed to in-patient treatment as the first option, rather than seeking and starting with community resources. The study points to out-patient as an equally viable treatment alternative, assuming detox is successfully managed. Finding effective, competent community-based help can be a challenge. One excellent resource is ASAM – the American Society of Addiction Medicine – to find a qualified practitioner in your area. Because prescribing the correct substitute medication and managing medication use over time is proven to be successful in improving outcomes, why not start with a knowledgeable, trained professional?
3. Many Residential Centers Offer Over the Phone Admissions w/o Screening or Intake Evaluation – 42% of for-profits and 20% of non-profits did not screen or perform an intake evaluation.¹ Screening and evaluations are standard practices to make sure in-patient is necessary and the patient’s needs can be met by the treatment center. ASAM has established placement criteria that indicates whether or not a substance abuser needs in-patient or out-patient treatment. (For more on the ASAM criteria See my blog: Looking for Help – Who do you believe?)  But many centers do not follow ASAM placement guidelines. As the consumer, avoid these treatment centers at all costs. Their selling point is immediate admission, no questions asked. But an unscreened patient population is a big unknown. And if there are no evaluations, how does the center even know what kind of treatment is appropriate for each patient? This is not “best practices”, it is “worst practices”.
4. Families Seek Residential Treatment on Their Own – …many desperate families and individuals seek residential treatment on their own.¹ Despite the failure of in-patient to be successful in reducing relapses, families still spend a lot of time seeking in-patient treatment for their loved ones without going through their health care providers or addiction counselors in their community. Families often turn to the internet looking for help only to find treatment centers paying to promote their services, often with multiple websites. Shows like Intervention also create the impression that in-patient is the only option for families, who are usually in crisis, looking for an immediate solution, and are vulnerable to patient recruitment techniques. Perhaps, the self-help approach reflects a desire for privacy or fear that disclosing an addiction concern to a health care provider may lead to increased rates. Or families may not know that out-patient treatment, when combined with medication, is an equally effective alternative model. 
   • Practice Pointer: Your LO may be reluctant to go in-patient. Offer the option of going to an ASAM addiction medicine specialist – a doctor – and emphasize seeing the doctor as an alternative to traditional treatment.
5. Patient Recruitment Techniques – these practices are designed to encourage a caller to sign up for in-patient care during the call. Practices include:
   • Immediate admission vs waiting a week or more (aka the “Buy now or lose your spot” psychological pressure tactic)
     • 79% of for-profit treatment centers offered same day admission vs a 7-day wait for a bed
     • 36% of non-profits offered same day admission vs waiting 23 days
   • Promoting luxury amenities
   • Justifying cost based on quality
   • Offering transportation assistance
   • Offering to talk to family members
   • Urging use of credit cards for payment
   • Referrals to interventionists who then use pressure tactics to get families to sign up for services. Some interventionists are said to overstate recovery rates and engender fear by telling callers their loved ones could easily die unless families sign up for an intervention
     •  Practice Pointer: If you are feeling pressured by these or other techniques, a good out is to say you have to talk to other family members or your “advisor” before making a decision. Get out of the emotional pressure cooker and contact your health care provider for a counselling referral.

The RRI Report reflects the tension between a prevailing in-patient treatment model versus the rising model of long-term, supervised recovery management in the community over many months, if not years. Critics of the in-patient model have long been concerned about these programs focusing on profits rather than quality of care. As the report states: While these findings concern a minority of (largely for-profit) treatment programs across the country, they nevertheless raise questions about the potential exploitation of a clinically and financially vulnerable population. In turn, such abuses point to ways that some programs are incentivized to prioritize profits over best-practices and high-quality clinical care.¹

You and your loved one(s) deserve effective, quality care. Don’t settle for anything less. 

Art Reflects Life: New Film Body Brokers Explores the Dark Side of Finder’s Fees for Treatment Patients

Unethical treatment providers are exploiting vulnerabilities to take advantage of families and addicts desperately looking for help. The three key ingredients:

• Infusion of cash (from parents and insurance)
• Inadequate regulation
• Vulnerable patients

With 22 million Americans struggling with addiction and alcoholism, and many often seeking help in a crisis with little information as to effective treatment, it is easy to see how this population can be manipulated by providers maximizing profit over service.

A recent article in Counseling Magazine, “Breaking the Body Brokers[i]” discusses California’s reform measures to restrict these predatory practices. Examples include selling addiction placement patients and paying people to relapse to reenter treatment. Other forms include providing housing and transportation to enroll in a center, and referral fees and financial relationships between drug testing labs, outpatient and housing entities.

• A seamy, sordid business too many families and their loved ones have been caught up in, leading to failed treatments and despair at ever recovering.

These are evil people, by the way – making money while our addicted family members and friends suffer and die.

The Film

A recent film, Body Brokers, captures the reality of this patient exploitation in ways that will turn your stomach and break your heart. Fortunately, California passed legislation restricting these practices. But few other states have acted, meaning that you as the consumer are still subject to the many tactics used to separate you from your money while duping you into believing your loved one is receiving excellent inpatient or sober housing care.

Isolating You From You Addicted Loved One

One problem is separating the addict from his/her family and other support systems. Once that happens, your loved one is open to exploitation because there is no one to be accountable to and the system lacks effective regulatory oversight. People who say, “I’ll take care of everything” or “It’s not your role to tell the addict where to go to treatment,” are to be avoided.

• Not only is family involvement the key to long-term recovery, but also the key to minimizing exploitation by treatment providers.

Keep this in mind as a first warning sign: Is your helper fully informing and including you in the entire evaluating and treatment selection process?

Common, Less Visible Referral Transactions

Pay Interventionist/Patient Finder (IPF) a Lump Sum for Treatment

In this scenario, the family pays the IPF a lump sum to cover both the intervention and treatment, say $50,000. The IPF then brokers the patient to the treatment center giving the lowest price for treatment and pockets the difference.

Quid Pro Quo

The IPF refers the patient to a treatment center with the treatment center referring the patient back for post-treatment services such as phone counseling and drug testing. Common practice now among high-end centers. 

Client experience: Family member goes to treatment from affluent family with several tricky financial issues. Treatment center sends the family member to their preferred aftercare provider who does not understand or address financial concerns. Plus, the level of service is less than needed to support recovery. End result, relapse with the family member refusing to agree to further help.

IPF Receives Referral Fee

Client experience: I was once called by a family whose adult son was in treatment at a beach resort treatment center that did not consider addiction to be a primary disease and instead were focusing on mental health concerns. He had a previous alcohol dependency diagnosis. How did the son select this center?  On the advice of the IPF.  I strongly suspected a referral fee was paid because there was no clinical reason for selecting this center.

IPF Gets Referrals Based on Patients Delivered

The treatment center gives more referrals to IPFs who provide more patients. Callers to treatment centers are given the names of IPFs who send the most patients to the center.

Web Internet Treatment Center Resources

Searching for addiction treatment on the web often leads the searcher to sites that pay to be promoted on search engines. These sites often are owned or run by the same group who then refer the caller to treatment centers that pay fees for these potential clients.

Remember The Basics

Standard Required Practices for Admission for Treatment

Many IPFs do not follow standard protocols required by regulations and professional standards for admission to inpatient treatment because doing so might likely dictate a less drastic alternative to such care. Plus, many IPFs are not qualified or licensed to apply these protocols. To be blunt, their goal is to send the patient (your loved one) off to treatment without determining if inpatient treatment is needed or the best option.

Diagnosis of Substance Dependence

Use the DSM-V criteria for the substances in question and assess the degree of the disorder, with three levels: mild, moderate and severe. A mild diagnosis usually does not warrant inpatient treatment.

Applying ASAM Placement Criteria

The American Society of Addiction Medicine has developed six criteria for evaluating the level of care, including inpatient:

• Acute Intoxication and/or Withdrawal Potential
• Biomedical Conditions and Complications
• Emotional, Behavioral or Cognitive Conditions and Complications
• Readiness for Change (Is the patient willing to go in-patient?)
• Relapse, Continued Use or Continued Problem Potential
• Recovery/Living Environment

These standards are used in deciding whether or not an addict needs to be treated as an inpatient or in the community.

As noted in a past blog, many treatment centers admit patients without going through any evaluation as to level of care or diagnosis. Avoid these centers. I also wish to remind readers that the authoritarian model prevalent in the addiction field is based on the idea that addicts and alcoholics need to be told what to do and their preferences ignored. Thus, families who only know this model, are vulnerable to sales pitches promoting in-\patient treatment over the objection of their loved ones needing help but wanting to try alternatives.

No Oversight – No Complaint Process – No Accountability

An additional super significant concern about working with patient finder/interventionists is that many are not subject to oversight by any regulatory bodies. This means that when the IPF engages in unethical behavior or provides incompetent services, there is no one to complain to.

What happens is that IPF and AA sponsors/members use their access and interactions to develop a relationship with your family member in early recovery.

• Then they use that relationship to exploit and take advantage of your loved one: sexual, economic or psychological abuse are not uncommon for our affluent loved ones.

The only recourse is to sue the IPF or sponsor. Few loved ones are in a position to do so and most families are too embarrassed to consider litigation, or they buy into the message that their loved one is at fault. Exploitation is a real danger and another reason to find professional help.

Resources for Professional Help

As emphasized, do not call a treatment center or interventionist or look on the internet for help. You will likely be caught up in this patient brokering, referral fee network that places making money at a much higher priority than patient well-being. And do not call your friend or friend of a friend in AA. Not only are AA recovery rates low, but you need professional help. AA members tend to think their way is the only way to stay clean and reject concepts related to successful recovery management programs.

Professional resources include the following suggestions to find help for your family.

• Use your Health Care Insurance and Call for a Referral to a Qualified Counselor
• Network of Independent Interventionists (NII)
• NAADAC Credentialed Counselors
• ICRC – International Certification and Reciprocity Consortium
• American Society of Addiction Medicine (ASAM) providers
• Physicians Health Programs (PHP)
• O’Connor Professional Group (OPG)

While I provide a short description and website reference below to most resources, my strong preference for the well off and well known is OPG. Next choice is to find an ASAM physician as they are used to working with a more affluent clientele. Remember the goal is obtaining help for you and your family and to come up with a plan to address your LO’s substance abuse.

1. Use your Health Care Insurance and Call for a Referral to a Qualified Counselor

This is the best option for families that cannot afford specialized help for their families. Use your insurance and find a counselor to help you and your family. For wealthier families there are better alternatives because many counselors do not understand the unique dynamics of affluent families.

2.  Network of Independent Interventionists (NII)

These interventionists are credentialed and independent of treatment centers. For example, the fourth of their policy guidelines for members is:

4^th: Being independent of treatment centers means that the interventionist has no financial ties to any residential treatment center through employment, retainers, or through any other arrangement that could render the interventionist partial or biased towards them.

• Go to the NII website to for a list of their members:

While there are not members in every state, most members will travel to meet you. And their approach to interventions is more oriented towards engaging the person with a problem in the process, rather than the “quickie” type of intervention. Also, note that most members also provide family counseling and can help you manage your loved one’s recovery journey.

3. NAADAC Credentialed Counselors

National Association for Alcoholism and Drug Abuse Counselors has different classes of counselors based on their educational degrees, experience and training.  The various categories are listed on the NAADAC website.  

For example, see the following credentialing criteria for a “Level One Counselor”

National Certified Addiction Counselor, Level I (NCAC I)

• Copy of GED, High School or higher diploma or transcript.
• Evidence of current credential or license as a Substance Use Disorders/Addiction Counselor or Professional Counselor (social worker, mental health, marriage & family therapist or LAP-C) issued by a state or credentialing authority.
• Written verification of competency in all skills groups by a supervisor or other health care professionals who have personally observed the candidate’s Substance Use Disorders/Addiction work for a total of three years full-time or 6,000 hours.
• Evidence of 270 contact hours of education and training in Substance Use Disorders/Addiction or related counseling subjects.
  • Must include at least six hours of ethics education and training within the last six years.
  • Must include at least six hours of HIV/other pathogens education and training within the last six years.
• Submission of a signed and dated statement that the candidate has read and adheres to the NAADAC/NCC AP Code of Ethics.

Did the interventionist you were referred to meet these standards? How about that AA friend of a friend? Likely not.

4. International Certification & Reciprocity Consortium

IC&RC is an organization that is made up of state and international boards that approve credentials and oversee examinations to make sure counselors meet minimum standards in their profession. Working with a counselor or other recovery specialist with an IC&RC certificate assures the client that the prospective counselor has been IC&RC standards.  See their website for a list of State Certification Boards.

5. American Society of Addiction Medicine

Find a certified addiction medicine provider. Go to the ASAM website. I like ASAM because the professionals can work with your family on an individual basis.  For example, a family business looking for help for a family member. Our local ASAM certified doctor offers an evaluation for under $500 dollars private pay. No insurance records. No hoops.

6. Physicians’ Health Programs (PHP)

Almost every state has a PHP program for addicted health care professionals. Some state programs sometimes will take on non-physician clients.  If not, they often are good sources for referrals to qualified professionals who are able to assist families. 

• These programs use the concept of “leverage” – using the license to practice medicine as the incentive for doctors to comply with treatment recommendations.

Therefore, practitioners should be helpful in using access to family resources as leverage to achieve the same end with your loved one.

See https://www.fsphp.org/state-programs for a list of state program offices.

7. O’Connor Professional Group, Inc (OPG)

Founded by Arden O’Connor after her brother had been through 20+ treatments, OPG works with families to develop effective strategies to encourage loved ones to seek help. OPG has a wide variety of recovery resources, including case management and companions for people in early recovery or struggling to quit using. And OPG keeps up to date on treatment centers in order to try and make a good match for clients. Well worth the price for an initial consult. OPG offers services throughout the U.S. and overseas.

Concluding Thoughts

These seven resources for professional, credentialed help for you and your family are credible, viable alternatives to the predominant patient finder/interventionist system with its focus on making money and resultant high relapse rates. You can and must do better. It may take a little more digging on the web for some of the resources, but it is well worth the effort, given the stakes.

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[i] Counselor Magazine, June 2021

Data On “Intervention” Methods

Success Rates for Three Intervention Models to Motivate People to Enter Treatment

OK, readers, time for an update on the daunting topic of how to motivate our substance-abusing loved ones (LOs) to agree to seek help, BASED ON RESEARCH.

So what does the research show regarding various approaches to encouraging alcohols and addicts to agree to enter treatment?[1]

Three Different Common Models

• CRAFT MODEL                                    64% Success Rate
• JOHNSON MODEL                             22% Success Rate
• Al-ANON MODEL                               14% Success Rate

This study randomly assigned 130 families to the three different models, with the success being defined as the addict entering treatment. What are the models?

Craft Model

The CRAFT (Community Reinforcement Approach to Family Training) model is described as collaborative, practical and respectful approach based on teaching families a set of positive strategies to interact with their LO with the problem.

Johnson Model

The Johnson Model is described in the book, I’ll Quit Tomorrow and popularized by the show Intervention. This model usually involves an early-morning visit to the LO’s residence by family members, under the guidance of an interventionist, who then read letters telling the target how much his/her addiction has hurt them, hope for the future and consequences if s/he does not immediately agree to go to treatment. This is the model that many interventionists (a.k.a. patient brokers) try to sell to families, with the goal of sending paying clients into treatment centers.

Al-Anon

Al-Anon recommends doing nothing and waiting for your LO to seek help when s/he decides to quit. I call this the “waiting for the light bulb to screw itself” model. This approach is one reason for the high death rates among addicts. Family members are often referred to Al-Anon by therapists, treatment centers or other professionals. I consider this malpractice.

Vital Information

The success rates for these models is vital information for family’s seeking help because they can overestimate (hope) for positive outcomes using these methods. Also, treatment centers and interventionists will oversell success rates to families to gain their business. The intervention game is an unregulated, anything-goes, buyer-beware sales market. (Note that there are better interventional models described further on [i.e., contingency management], but the emphasis in this first part is on research on the probabilities of success for these three common approaches.)

RECOVERY RATES
20% or Less at One Year

As I discuss many times elsewhere, recovery rates from treatment are low, less than 20 percent at one year, according to reliable studies. As with interventionists, any representations or reports about success rates for treatment are unreliable because the industry is unregulated.

So even when your LO does agree to go to treatment, the expected outcome is relapse. 

Which is why, my goal is to educate concerned family members and friends about data-driven models that improve the odds of sustained recovery, compared to the above models. The reader will see that by combining success rates for getting people into treatment and success rates for sustaining recovery after treatment, the likelihood of success is low.

Example: 22 percent under the Johnson model go to treatment. Of that 22 percent, 20 percent will be abstinent at one year. QED: The likelihood of recovery is 4.4 percent (22 percent x 20 percent) for those intervened on using the Johnson model.  Even if off by 500 percent, these are poor odds.  Keep in mind that the treatment center/interventionist cohort is a business, with substantial income generated by former patients who relapse. There is scant economic incentive to adopt highly effective recovery models.

War Between Old Ways and Evidence Based Practices

Right now, there is an active war going on in the addiction treatment field between the old ways practiced by treatment centers and AA sponsors and evidence-based practices based on research.

Example: A family business member returns from treatment. A member of a family business, Bob, is in treatment for the second time and the family is concerned about his return to his job in marketing involving entertaining, where alcohol is present.

Treatment Center/AA Sponsor: Bob is responsible for his own recovery and the business should make no changes or require any oversight measures. If Bob fails, he suffers the consequences until he gets the miracle of recovery.

Family Business Position: Business leadership wants Bob to sign a Return to Work Agreement, similar to agreements for pilots and doctors resuming work activities. These agreements provide for regular drug testing, changes in the work environment to reduce the risk of relapse, counseling requirements and similar accountability measures. From the family business perspective, they can’t afford Bob to relapse and harm the business and they are concerned about maximizing Bob’s opportunity to become sober.

Ongoing Warfare: This dispute is common and reflects what I call the treatment center/AA “mafia” hold on advice to addicts and family members that so often leads to relapse, versus the much higher, evidenced-based recovery outcomes of the pilot/doctor programs. This war between the two dramatically different approaches is ongoing for over 20 years, with no end in sight.

Going to Treatment is NOT the Same as Deciding to Recover

The kicker here, of course, is just because your LO agrees to GO to treatment does not mean s/he will WANT to recover or be able to SUSTAIN recovery. 

• Got it? The decision to seek help is only the beginning.

Many people decide in treatment they do not want to quit, do not want to do what is necessary to maintain abstinence, or – even if they want to be abstinent – are provided an inadequate post-treatment program and relapse. Therefore, in the next section, I will review more successful intervention models using some form of contingency management or leverage.

Leverage – Pressure – Incentives – To Seek and Sustain Recovery

Other, more successful motivational models: Treatment Courts, Incentives, Doctor/Pilot Leverage Concepts

CRIMINAL JUSTICE SYSTEM – TREATMENT COURTS

From the National Drug Court Website (NADCP.org):

Treatment courts are the single most successful intervention in our nation’s history for leading people living with substance use and mental health disorders out of the justice system and into lives of recovery and stability. Instead of viewing addiction as a moral failing, they view it as a disease. Instead of punishment, they offer treatment. Instead of indifference, they show compassion.

Treatment court judges are said to have higher success rates than treatment centers!

Treatment courts are both a model to encourage people to seek help and to keep the pressure on until the addict can sustain recovery on their own. In the context of our work with families, a criminal incident can be used as leverage to encourage a loved one to seek help. However, most often families marshal their resources to make incidents go away. Not only is a treatment opportunity lost, but the addict learns the family will come to his rescue, no matter his/her behavior.

Example: A young adult steals money/objects from parents’ home. In this situation, we commonly suggest that the parents ask their lawyer to find a criminal defense lawyer to represent their child with the goal of a plea agreement requiring successful completion of treatment in exchange for dropping the charges. It is most successful when the prosecution is informed of the desired result before the parents bring the charges. One common problem occurs when a parent or other family member subverts the system when the young adult is noncompliant with the plea agreement.

INCENTIVE-BASED SYSTEMS – ASAM – CONTINGENCY MANAGEMENT

As reported previously, the American Society of Addiction Medicine (ASAM) states[2]:

Contingency management has been studied and shown to be effective in the treatment of many substance use disorders, including opioid use disorders, cannabis use disorders, and stimulant use disorders. Importantly, it is the only evidenced-based treatment for stimulant use disorders. …… The National Institute on Drug Abuse (NIDA) also promotes contingency management as a highly effective approach to increase treatment retention and promote abstinence from drugs.

I recall reading several studies that indicate using contingency management in combination with community-based support services can double recovery rates for the chronic low-income using population – perhaps up to 40 percent. 

DOCTOR/PILOT PROGRAM – CONTINGENCY MANAGEMENT

Programs run by airlines and medical boards for substance dependent pilot and doctors, respectively, have the following recovery rates:

• Pilots:          92% continuous abstinence at two years
• Doctors:     84% continuous abstinence at five years[3]

The pilot success rate was first reported in the Hazelden Treatment Center Newsletter, Voice, in 1998. Pilots, like doctors, are offered a special treatment program unavailable to the general public. The contingency management component of the program is simple: You comply with all treatment recommendations and you can fly or practice medicine again. Very effective.  We find using access to money and other family resources is often a very compelling tool in encouraging family to seek help and stay focused on recovery.

Closing Comment

Let’s use research and data to make treatment decisions concerning our loved ones. Most readers are likely in high states of anxiety – looking for help and worried sick about their son, daughter, sibling or parent with a serious using disorder. But keep in mind the data. Don’t settle quickly for a solution with a low chance of success. This is not like horseshoes. Close is not good enough, and you may not get another turn to pitch that shoe.

In the next several blogs, more information on leverage.

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[1] Miller, Meyers and Tonigan, 1999 Study,

[2] Letter to HHS Secretary Azar, July 6, 2020 from ASAM, by WF Haning, MD

[3] The New Paradigm for Recovery: Making Recovery – and Not Relapse – the Expected Outcome of Addiction Treatment A Report of the John P. McGovern Symposium Hosted by the Institute for Behavior and Health, Inc. November 18, 2013, Washington, DC

BUT A THERAPIST-LED GROUP IS PREFERRED

Why Groups Work and How They Help Participants

Research now shows that any group participation is as valuable as AA 12 Step participation. Treatment centers, counselors, and courts routinely require people to attend AA 12 Step groups as part of their treatment plans or conditions of probation. Fortunately, the researchers at Harvard’s Recovery Research Institute (RRI) published this article:

“It works, but why does it work? Perspectives on change in 12-step and non-12-step mutual-help groups”

• Findings: Non-12 Step Groups seem to be as effective in supporting change as 12 Step Groups.

WOW — great news!

Self-help groups include SMART Recovery, LifeRing, Women for Sobriety, All Recovery Meetings, Recovery Dharma/Refuge Recovery and all manner of less informal groups.

Remember AA and the 12 Steps are simply one of many behavior change models. This report reviews studies that show any group process is as effective as attending AA and other 12 Step Groups in effecting behavior change.

Now – based on this study – people can respond by finding groups that fit their needs and interests. In particular, attending groups led by a counselor is a valid alternative to attending 12 Step groups.

Participant-Described Benefits of Self-Help Groups[1]

1. Perspective: Listening to other members describe how they dealt with problems promoted self-awareness and an ability to adopt new perspectives.

2. Being Connected to Others: The importance of friendship and bonds among group members; being accepted despite their past; stability and safety provided by the group; and the importance of giving and accepting support.

3. Developing Skills: Learning tools that they can transfer to other areas of their lives, including avoiding triggers, setting goals, self-monitoring, and other coping skills.

4. The Value of Group Activities: These activities allowed participants to develop new interests and promoted a sense of achievement. Participants said new activities were a substitute for time previously spent using.

5. A Change in Self:  Recovery groups provided the hope many individuals needed to be able to change. Many individuals attributed their recovery entirely to group involvement, the change in self allowing them to recover.

Most people trying to quit or in early recovery are told to attend groups, but not the reasons why to attend groups. The attitude is “Yours is not to reason why, yours is to do and try.” This authoritarian approach is no longer effective or appropriate (if it ever was). The RRI information as quoted here is excellent information to give to people considering attending a group or recommended to attend a group. It explains the benefits from group attendance.

Psychological Theories Underlying Beneficial Effects of Groups[2]

According to RRI, groups reflect four psychological theories:

1. Social Control Change: Bonding between group members, goals set by the group, and structure.

2. Social Learning Theory: Learning group norms and emulating role models.

3. Behavioral Choice Theory: Rewarding activities other than substance use.

4. Stress and Coping Theory:  Building coping skills and self-efficacy to manage the stressors that lead to use.

These theories explain why group participation is such an important component of a recovery program or plan.  But it can be any group, not just a 12 Step group.

The bullet point summary of the benefits includes the following:

• Bonding and support
• Goal direction
• Structure to follow
• Available role models
• Expectations of positive and negative behavior
• Involvement in protective activities
• Effective rewards
• Identifying high-risk situations
• Building self-confidence
• Developing coping skills
• Giving back
• Presence of like-minded individuals
• Developing self-awareness and reflection skills

What a great list for counselors and professionals assisting the family in managing the recovery process and for evaluations of progress from that last drink. 

The Importance of Group Participation for Substance Users

Many years ago, I read a book on groups with a specific emphasis on the benefits of groups for substance users. The author noted that for alcoholics and addicts, groups were more important to achieving sustained recovery than individual therapy. I believe this is an accurate statement if the group is a safe place for participants and participants can identify with their group members. This is one reason why specialized groups can be much more powerful generators of recovery than generic groups. Business executives, LGBT, women, minorities, pilots, doctors, lawyers, the affluent and prominent, etc. all benefit from feeling comfortable with others from a common background.

Problems With 12 Step Groups, Including AA

Many people refuse to attend or quit after several meetings for many different reasons:

• Reference to God and recitation of the Lord’s Prayer
• Concept of Powerless – minority groups and women reject this idea
• Exploitation of new participants by group members (13^th stepping women, a common problem)
• Dictatorial direction by sponsors and other long-time members
• Misinformation and downright bunk presented at meetings
• Uneven and variable meeting content
• Ineffective/inaccurate, dangerous or punitive advice regarding relapse and family relationships

The latter comments highlight the downside of self-led volunteer groups with required or recommended attendance. People in early recovery or trying to quit are thrown into what can often be an antitherapeutic, exploitative environment.

Here is the problem with 12 Steps groups for the affluent, well-known and women:

We normally have our guard up.

However, in attending AA, we are told to be more open, trusting, and honest about who we are in order to benefit from group interactions and sponsorship. Unfortunately, there are people in meetings to take advantage of newcomers – sell them drugs and otherwise exploit sexually or financially. There are also participants who appear to be sincere, but have dual agendas – gain a client, find a sexual partner, tout their relationship with a famous person, borrow money, etc. It is a minefield, particularly for young people who have fewer skills in identifying potential victimizers. Fortunately, the RRI Report supports attendance at non-12 Step groups run by a qualified professional, which should reduce potential for exploitation.

Professionally-Led Groups Preferred

In my experience, groups led by professionals are far better than self-led groups because the professional can keep the group on track, identify members in crisis, make sure boundaries are maintained, provide guidance on issues, and assess progress. It is also far better to pay out of pocket for groups than try and go through insurance. Finally, professionally led groups can help preserve the privacy and anonymity of group members – a particular problem for the affluent, well-off and well-known.

Why do I say to avoid insurance? Insurance requires ongoing documentation for the reasons for attending group, and you want to avoid creating an insurance record that will follow you forever. Plus, insurance limits the number of sessions.  Finally, the quality of health care provider therapists is said to be lower due to high case load demands from health care companies. Upshot: Go private therapist and pay out of pocket for your group experience.

My AA Experience

I attended AA meetings regularly for five years because it was a safe place to gather my thoughts and hear from other people about their experiences. However, it seemed like a tough recovery environment for many attendees – lots of mixed advice and long-winded repetition. I stopped attending when members I knew from treatment expressed their resentment at my five-year medallion ceremony because I was affluent.

My experience in attending AA is that meetings are not, in fact, anonymous. People probe to try and figure out who you are, where you live, etc. It is said that treatment center personnel leak names, as do group members. My most beneficial experiences were attending groups led by a counselor and volunteering with group members at a local homeless shelter.

To reiterate, I would not recommend 12 Step recovery groups to the well-off and well-known – the pitfalls outweigh the benefits. Find a good group led by a counselor and start your own group. I have been in a men’s group with friends for over 30 years, and that has been helpful.

The Recovery Research Institute (RRI) out of Harvard publishes a monthly newsletter reviewing research on effective approaches in treating substance use disorders.

Each month I will select several impactful topics of interest to family, friends, and users in recovery or considering quitting or cutting back.

• RRI has really good information that often contradicts or significantly modifies current recommendations from treatment centers, professionals, and amateurs offering advice as “interventionists.”

RRI is a non-profit. I hope readers who find their research beneficial will consider donating to RRI.  See RecoveryResearch.org. There is an incredible amount of misinformation about addiction and recovery that is downright dangerous, given the lethal nature of SUDs. Time to turn to science from reliable institutions.

Personal Insight Note: Addiction Field Lacks Intellectual Firepower

Fifteen years ago, I was lying on a hospital table waiting for a cortisone injection into my hip by a doctor trained at Harvard and MIT. It dawned on me that the addiction field lacked the intellectual firepower prevalent in treating other diseases.

• People involved in addiction services tend to be a self-selected group in recovery representing one percent of the population.

The math on this group, using some general assumptions is: 10% of the population is addicted. 10% of this 10% is in recovery – 1% (10% of 10%) is the pool drawn to working in the addiction field. This is a tiny group to draw from, and many lack the skills and innate talent to be effective counselors and services providers, let alone the professional ethics and boundaries to work with people in distress.

The advent of academic research from respected universities is a welcome and much needed addition to the field.

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[1] RRI Bulletin, p. 8 May 2021

[2] RRI Bulletin, p. 10 May 2021

In the event your partner expresses an interest in quitting, you can say:

“Funny you say that, I recently came across information from Harvard Medical School about their recommendations for quitting.”

Or perhaps you are wanting to quit. 

The five-step action plan from Harvard Health looks like a good one. It treats drinking and drugging as a pleasurable habit gone awry.  Now you need to learn a new habit — abstention.  No judgement involved.  Let’s solve this problem.

I wish it were so easy!

But before reviewing the action steps, first heed this warning: Withdrawal from alcohol can be life threatening.  Same for benzos (e.g., Xanax, Valium, Ativan, etc.).  Keep in mind that if your loved one has been secretly drinking more than you know and quits, s/he may be in withdrawal, so you need to know the symptoms. More on this important topic at the end of the five-step action plan.  

Five Action Steps Suggested From Harvard Medical School

Harvard Health Beat recently sent out an e-mail advertising their “5 action steps for quitting an addiction.”  Not to be confused with the 12 steps of AA, the five steps are from a larger pamphlet the medical school offers online or as a hardcopy pamphlet, “Overcoming addiction with 30 proven strategies for conquering addiction and sustaining recovery.”

Their tag line is: Learn how to effectively address – and end – dependence on alcohol, stimulants, nicotine, opioids, and more.

Harvard also hosts The Recovery Research Institute.  The Institute publishes valuable information on what seems to work to improve recovery outcomes at www.recoveryanswers.org.

In my view, the SUD treatment field has lacked critical brain power in the past, and it’s one of the reasons recovery rates have not improved much. But this is now changing with institutes at academic institutions around the country investing in behavioral and neurological research. 

Five Action Steps for Quitting an Addiction (Italics From Harvard Health Beat)

Because change is so difficult, it is useful to have a guide when attempting to kick an addiction to drugs, alcohol or behavior.  Research shows that the following steps can help you move toward your recovery goals. You have the greatest chance of success if you adopt all five steps.

1.  Set a quit date

It might be helpful to choose a meaningful date like a special event, birthday or anniversary. 

My comment: No need to call yourself an alcoholic or addict. Simply say, “I am not drinking today,” or “I am a non-drinker at the moment.”  

Consider a month-long period of non-drinking, like Dryuary for January.  See how you feel and note the challenges you encounter during your dry days. 

2.  Change your environment

Remove any reminders of your addiction from your home and workplace. For example, separate from those who would encourage you to be involved with the object of your addiction (drug, alcohol, or behavior).  If you are trying to quit drinking, get rid of any alcohol, bottle openers, wine glasses, and corkscrews.  If you’re trying to quit gambling, remove any playing cards, scratch tickets, or poker chips.  Also, don’t let other people use or bring reminders of addiction related substances or behavior into your home.

Excellent advice. But caution: Note that some treatment centers and AA members say doing the above is unnecessary for people truly committed to abstinence.  They advise family members and friends to do nothing to accommodate their loved one who is now abstinent and in early recovery.  For example, if having alcohol in the house leads to relapse, then, in their view, it shows the alcoholic needs to spend more time suffering before s/he develops the willingness needed to recover.  This position is absolute BS. 

Family members listening to this nonsense have contributed to many relapses.  Examples:  

• Tech exec with giant wine cellar unwilling to store it offsite when wife is in early recovery.  
• Parents insisting children should attend alcohol-soaked family events or resume country club socializing shortly after leaving treatment.  
• Business exec insisting spouse go from treatment to annual meeting in Hawaii.

Listen to the experts from Harvard.  Their advice is based on research and facts.  

3. Distract yourself

Instead of giving in to an urge to use, come up with alternative activities, such as going for a walk or calling a friend or family member to talk, so that you can keep busy until the urge passes.  Be prepared to deal with things that trigger your cravings.

• Urges pass – but they can seem overwhelming.  

This is one reason why liquor and pills must not be in the house – to increase the amount of time and space between the urge and acquiring the substance so the urge passes.  By prolonging action based on impulse, your loved one can think through the consequences of picking up again. 

4.  Review your past attempts at quitting

Think about what worked and what did not.  Consider what might have contributed to relapse and make changes accordingly.

Do more than think. Write it down an “Action Plan” and diary your thoughts.  Review with counselor or other support person(s). 

5.  Create a support network

Talk to your family and friends and ask for their encouragement and support.  Let them know you are quitting. If they use your object of addiction, ask them not to do so in front of you.  If you buy drugs, you should consider telling your dealer that you are quitting; ask your dealer not to call you or and not to sell you drugs.  

My comment: Change your phone number.  

Also, you might want to consider talking to your health care provider about the method of quitting that is best for you.  There may be medications that can ease the process for you and to increase your chances of success.

My comment:  Definitely see your doctor before quitting due to concern about withdrawal risk.

Also, because we have so much shame and frustration over our use, it is better to find a good counselor or friend in recovery, because interacting with family is often very triggering due to their anger and advice-offering.

Withdrawal Dangers

Because our body’s tolerance to alcohol and drugs increases over time, stopping suddenly can lead to withdrawal, which can be life threatening.  Same for benzodiazepines (e.g., Xanax, Valium, Ativan, etc.)  The severity of withdrawal symptoms varies by individual, meaning people who drink relatively small amounts of alcohol may have severe withdrawal side effects.  

• When your loved one decides to stop, s/he is very likely to be underreporting their alcohol or drug use, thereby being vulnerable to withdrawal symptoms, without you knowing it. 

People with problems always underreport to family members the extent and severity of their drinking and drugging.  “I am only drinking, and smoking weed.” But when we talk to them privately regarding their use or see their drug tests, invariably the number substances and quantities are off the charts.  

Signs of withdrawal include:

• Increased heart rate and/or blood pressure
• Sweating and tremors
• Confusion
• Seizures
• Cramps
• Body aches and pains
• Hallucinations

Advice and request:  See your doctor when you decide to quit.  Your physician can prescribe withdrawal medications to reduce cravings.  

Liver disease up 300% …
Worried discussions with physicians …
What to do?

Being active in the SUD recovery field means I hear a lot about trends from health care providers:

• OBGYN – Many more patients discuss concerns about drinking too much.
• Liver Specialist – 300% increase in liver disease since 2019, many in their early 30s.

As for me? Calls and e-mails coming in from families and friends worried about excessive alcohol and drug use by the men and women in their lives.  Apparently, the one or two glasses of wine at the end the day is now morphing into three or four (or maybe more – it’s hard to keep track).  And the corkscrew is being activated earlier in the day.

Reports that women are drinking 30% to 40% more alcohol compared to last year confirm the anecdotal information from callers and colleagues.  One response, when concerns are raised, is “What’s the big deal? Wine is my stress reliever; I’ll cut back when COVID’s over!“

But the question is: Can you? And, what are the risks in continuing on?

While it may be a great relief to relax and numb out a bit as the day drags on or winds down, persistent use can take you to the edge of losing control.  For most people, loss of control over how much to drink or when to drink is crossing the line from recreation and relaxation to dependence. 

Regaining mastery over that bottle is a familiar struggle for all us alcoholics.  “Damn, why can’t I drink like I used to?  Too bad, that horse is out of the barn.”

Rather than engage in this frustrating struggle, better to face facts (unpleasant as they may be).

Fact #1: Different Bodies – Variable Impact

Not everyone processes alcohol or is affected by alcohol the same way. As reported in the LA Times*, hospitals are reporting a significant increase in liver disease in 40-year-olds who are unexpectedly susceptible to the toxins in alcohol processed in this vital organ.  (Yes, alcohol is a poison.)  

• Some people deteriorate rapidly; some go on seemingly forever. 

Why risk drawing the short straw?

Fact #2: Alcohol Kicks our Butts as we Age

As we age, we are less able to process alcohol through our system, meaning at age 40 we can’t drink as much as in our younger years. 

Fact #3: Check out These Signs of Excessive Alcohol Consumption

• Having trouble caring for your children and being present for them
• Feeling tired, irritable, and unmotivated
• Experiencing headaches and noise sensitivity
• Being depressed and anxious
• Increasing conflict in relationships
• Hiding alcohol use from loved ones

(The two-by-four of reality can no longer be disregarded so easily.)

Fact #4: Jeopardizing Children’s Safety

• Common Complaint:  Drinking and driving with the kids in the car.

Are you dropping your kids off at practice and then attending Parent Practice at your local pub while you wait to pick them up???  (AKA drinking and driving?) If you are caught, you will face a DWI and a possible child protection referral.

• Another problem:  Spouse out of town for work.  Stay-at-home drinking parent is unable to respond to child’s request for help or other nighttime emergency.

And sometimes there is a medical emergency.  (Being a CD counselor means I hear a lot of horror stories.) Children do remember not being able to wake you.

Fact #5: Good Times Around the Corner

COVID downtime may be an excuse to drink, but what happens when we can all go out and party like it’s 1999?  We will celebrate by going to restaurants, bars and friends’ houses.  No way you are going to cut back. ‘

• Now is the time to limit yourself to one glass a day and see what happens.

If you have trouble doing so, watch for my blog post later this week, “Five Steps to Stopping On Your Own,” based on suggestions from Harvard Health.

Five percent or so of American’s suffer from liver disease.  You don’t want to join this club, face a DWI, suffer an accident with your kids in the car, or be the stereotypical wasted parent!

_{*”As Alcohol Abuse Rises Amid Pandemic, Hospitals See a Wave of Deadly Liver Disease,” LA Times, Feb. 8, 2021}

Time to Put to Rest this Purveyor of Uninformed Guidance and Malpractice

Founded in 1951 – Stuck in the ‘50s

One significant flaw of Al-Anon is its failure to incorporate new evidence-based practices on what works for recovery into its curriculum and advice packets for family members.  Founded in 1951, when AA was the primary path to recovery, the Al-Anon philosophy remains unchanged despite years of research and progress in identifying successful approaches to recovery.  Unfortunately, it’s message – “Let Go and Let God” – continues to permeate the alcohol/addiction field, often to the fatal detriment to families and their loved ones.

He Doesn’t Want Treatment

Let’s look at some examples from our practice on why Al-Anon is a significant barrier to successful treatment by first explaining a common experience in working with client families.  Once again let’s turn to a parent’s letter to our local paper:

I think often about one of my son’s best friends.  His mother is trying tirelessly to get him help, while the boy’s father contends that treatment won’t work because his son doesn’t want treatment.

This statement captures both the Al-Anon message and our experience with families in a nutshell: the notion that we are powerless over our addicted loved ones and must wait until they want treatment.  To reiterate, this attitude flies in the face of reputable, proven studies to the contrary, and more importantly, risks further deterioration and possible death, given the availability of legal and non-legal drugs in today’s world. 

Wastes Time and Emotional Energy

In our work with clients, one goal is for all the players in the family “system” to be on the same page and commit to an action plan that encourages their LO to seek help.  Why? 

• An addict is like mercury, if there’s a crack in the system, s/he will slip right through.

We waste a lot of time and emotional energy educating and persuading key participants on the evidence and benefits of a persistent, activist approach in addressing addiction in their LO.  This counseling (and money) would be better spent working out scenarios and plans, rather than disabusing a relative or advisor of ineffective Al-Anon nonsense.  Plus, families have limited willingness to engage in what can often be a contentious effort.  Dissipating focus fending off Al-Anon BS often results in families losing interest in continuing on in what, by nature of the disease, is a long journey.

Al-Anon Pathology Infects Families, Kills LOs

Aside from squandering valuable time and resources in organizing the family system, this notion of letting go and letting the addict take responsibility pervades the whole recovery process and provides the justification for prematurely reducing or terminating oversight services such as recovery management, drug testing and treatment plan adherence.  What does this mean in practical terms?

Family Founder Client

The founder will often tolerate our assistance until the crisis passes and then fire us for the ostensible reason that the person with a problem (PWP) needs to take responsibility for his/her own recovery.  The real reason is that the founder does not like outsiders interfering with his/her authority within the family.  Despite being successful in business, founders reject information about what works for recovery and instead hang on to the siren song of Al-Anon as justification for terminating services.

LOs in Early Recovery 

Young addicted adults are used to running free, fueled by family resources, with occasional ostensible attempts at stopping or cutting back.  The last thing they want is someone to manage their compliance with treatment recommendations for six months.  Shortly after returning from treatment, they begin lobbying to get rid of us, saying they can do recovery on their own, we are too expensive and rigid – whatever argument they think will be most effective within the family. 

Family Advisors, Trustees and Professionals

To this group, we are a threat to their authority and client relationships.  Often providing ill-informed, ineffective advice to their clients, they are now faced with the prospect of addiction experts supplanting them as trusted confidants. 

“The addict/alcoholic in early recovery is doing so well, let’s return to the old system.”  And that’s the end of it.  So long, family members, with the next news being in the obituaries.

Sustained Remission Starts at 12 Monthsⁱ

What’s happened since 1951?  Well for starters there is the DSM, and now the DSM-V.

Think about it. 

• What if the Al-Anon website informed viewers that times have changed, and science-based information now exists that will help be more effective in assisting their loved ones achieve stable recovery?
• What if the National Association of Children of Alcoholics website did the same?

And what if viewers were then referred to information based from the DSM-5, or reputable research from academic centers such as Harvard or Yale, or stories as to how families actually implement recovery management or crisis-response planning.

Example – Sustained Remission After 12 Month

The DSM-V denotes the months four through 12 after abstention as Early Remission, meaning whatever you are doing as a family to encourage your LO to stay clean, keep doing it for at least a year. 

Example – Crack House Extraction

When Bill Moyer’s son WC was in the crack house, Bill went down and helped get him out. He didn’t “Let Go” and wait for WC to seek help on his own.

If they say crack is wack, then Al-Anon is even wackier – no sane relative waits for their LO to leave a crack house or stop shooting heroin on their own.

Treatment Centers Nix Family Counseling

Several years ago, we partnered with parents in counseling their young adult child on the benefits of treatment.  She agreed to enter a 28-day program, with the understanding that we would continue on after she completed her program. We did not hear from the parents and decided to call them about scheduling an appointment.  Their response: 

While at the family program we asked if we should continue counseling after treatment and we were told there was no need to do so, just attend Al-Anon.

This typifies the archaic thinking all too common in the treatment centers. 

(Practice Pointer Aside: Now many centers are capturing the post-treatment dollars by setting up their own counseling services or sending patients to outside groups in exchange for referrals.  Particularly if you are from a well-off or well-known family, avoid these post-treatment services at all costs.  Find your own resources and fend off pressure tactics to buy their programs.)

Another Consideration: Your LO is Very Likely a Vulnerable Adult

Us users go to inpatient because we have trouble stopping drinking or drugging on our own.  When we do imbibe or ingest, on occasion, we become unable to manage ourselves and/or become a danger to others.  And, one of the hallmarks of addiction is the inability to make consistently good decisions regarding seeking and following inpatient and post-treatment recommendations. 

• Family members play an important role as advocates for their LOs, who by definition, are often limited in their ability to think clearly.

This role is similar to the one performed for relatives facing serious chronic diseases such as cancer, diabetes or aging. 

PAWS Impacts Judgement

Post-Acute Withdrawal Syndrome (PAWS) also negatively affects decision-making in early recovery.  Providers are well aware of this impaired judgement, but conveniently use HIPAA and Al-Anon concepts to isolate their patient and fend off information-sharing and questions from relatives.

Case Example: Son returns from treatment and tells Dad they told him he could continue to drink and smoke weed, but to stay off the cocaine.

This is segregating the patient and family to the extreme.  End result disaster. Shameful practices, but completely consistent for an industry focused on profits and executive salaries, not patient care or outcomes.

Blaming the Substance User

What happens with relapse? We blame the substance dependence person – the person with the problem who has a disease and is a vulnerable adult.  It is so easy to do, and the Al-Anon philosophy fits right in: They must want to recover for treatment to work.

• Parents, family members and their support staff are already angry at the PWP. 

Most PWPs are so ashamed and frustrated after they first pick up that they are perfectly willing to accept the responsibility for their failings.  The benefits of being both in recovery and family-focused is we can step right in and try to intercede with information and persistence, including “The Disease Concept (understanding addiction as a chronic disease)”; “Relapse is not Failure”; and “Let’s Rework the Recovery Plan”. 

But it’s a tough slog, given all the misinformation out there.

Let Her Go – Kick Her Out (Flawed Advice!)

Some years ago, I was contacted by parents whose 21-year-old daughter had failed three treatments.  They were being advised to practice tough love (i.e., cut her off and let her live on her own).  In fact, the three treatment centers were at fault for lousy treatment, and as someone from a wealthy family, she got nothing but crap from her peer group.  Who could recover in that environment? After working with the family to try different approaches, I was so disturbed by this very common scenario – blame the addict, kick her out – that I wrote:

Flawed Family Assumptions About Addiction:
What You Think You Know About Alcoholism, Addiction and Treatment Can Hurt You and Your Loved One

Before you get fed up with your son or daughter or relative, read this article.  Also look for my third blog on my family’s experience with inaction and a short research review on successful approaches incorporating family/advisors in the recovery process.

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[i] Diagnostic and Statistical Manual of Mental Disorders, 5^th Ed., American Psychiatric Association

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:

1. Bill Wilson, AA founder, developed the principles underlying Al-Anon.
2. 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.