I’M TRYING TO BE LOGICAL AND REASONABLE

PLEASE READ THIS ENTIRE POST AND THINK IT OVER…

One of the most troubling aspects of the modern-day “substance use disorder” treatment system is the stubborn reliance on a single pathway of recovery.

Namely, 12-step recovery. Mostly, AA and NA meetings/programs.

I found recovery through 12-step meetings and it is my preferred pathway to recovery.

However, in my professional work, I avoid pushing my recovery onto others. Sadly, the reality is, many providers still push 12-step only recovery.

YOU MUST COMPLY

Mandated programs and compliance programs almost always have a “recovery group” attendance requirement.

And far too often they sadly: ONLY ACCEPT 12-STEP RECOVERY GROUP ATTENDANCE.

This runs counter to all the facts and research surrounding recovery.

For example, let’s review the numbers.

THE NUMBERS

There are 22.35 million people in America who report having resolved a substance use disorder.

• They “had a problem”.
• They “no longer have a problem”.

I hope we can all agree, that resolving a SUD is a good thing. Regardless of how you get it done.

REQUIRED HELP

Of those 22.35 million people, 54% report that they had assistance in getting better.

In other words, 12,069,000 required help.

AA & NA

Of those 12,069,000 who got help, only 45% report that it came via AA or NA.

Therefore, 5,431,050 FOUND RECOVERY THROUGH AA or NA.

THE OTHER ALMOST 17 MILLION

THIS MEANS THAT 16,918,950 PEOPLE GOT BETTER VIA SOME PATHWAY OTHER THAN AA OR NA.

YET WE HOLD TIGHT TO THE IDEA THAT AA AND NA IS THE ONLY OPTION?

And we “professionalize” that by hanging steps in our treatment group rooms and mandating attendance to “12-Step Groups Only”.

FOR 12 STEP ENTHUSIASTS

Pause for a station break.

At this point, if you are a 12-step only enthusiast you have a couple options:

• You can flat out deny the research and simply say “in my experience, this is the only way”.
  As if your experience speaks for the other 7 billion people on the planet. Or you can –
  
• You could deny the math. But run the numbers, it’s indisputable.

WHAT DID BILL BELIEVE

Finally, even the founder of Alcoholics Anonymous would reject this idea of “12-Step Only Recovery”.

Mr. Wilson would be appalled by the hubris and arrogance of promoting one way only.

Here are some quotes from Mr. Wilson.

Thank you to a global Alcoholics Anonymous expert, William White for the research:

• “AA has no monopoly on reviving alcoholics”. (Wilson, 1944/1988, p.98)
• “The average member of Alcoholics Anonymous does not suppose we have a cure- all”. (Wilson, 1945b, p. 239)
• “In all probability, we shall never be able to touch more than a fair fraction of the alcohol problem in all its ramifications. Upon therapy for the alcoholic himself, we surely have no monopoly”. (Alcoholics Anonymous, 1955, p. ix)
• “In no circumstances should members feel that Alcoholics Anonymous is the know-all and do-all of alcoholism”. (Wilson, 1965/1988, p. 332)
• “Then, too, it would be a product of false pride to believe that Alcoholics Anonymous is a cure-all, even for alcoholism”. (Wilson, 1963/1988, p. 346)
• “When you consider the ramifications of this disease, we have just scratched the surface. I think we should humbly remember this”. (Wilson, 1969, p. 9)

ON DOGMA & COERCION:

“It is a historical fact that practically all groupings of men and women tend to become more dogmatic; their beliefs and practices harden and sometimes freeze. This is a natural and almost inevitable process…. But dogma also has its liabilities. Simply because we have convictions that work well for us, it becomes very easy to assume that we have all the truth….This isn’t good dogma; it’s very bad dogma. It could be especially destructive for us of AA to indulge in this sort of thing”. (Wilson, 1965/1988, p. 333)

REASONING

It stands to reason that:

1. The science and evidence supports opening the door to “Alternative Recovery Programs”.
   
2. Bill Wilson would support alternative recovery models.

The questions that naturally arise are:

• Why don’t more providers open the door to “Alternative Recovery Models”?
  
• Why does the system allow such inappropriate conduct?

FOR THE RECORD

For the record, there are amazing programs in Greenville and the rest of the Upstate that completely support alternative pathways.

However, it is troubling that old school hold-outs are still permitted to operate.

Full report: https://www.recoveryanswers.org/…/1-in-10-americans-report…/

The post LOGICAL AND REASONABLE AS PLATO appeared first on The Recovery Cartel.

Recovery Slogans

Terms like “rock bottom” and “willingness” could be viewed as nothing more than slogans batted around at various self-help groups. It that were the case there would be little need for alarm.

Recovery slogans are common sayings put forth by people who volunteer their time to help others.

These folks have no ethical obligation to look beyond their own personal experience.

However, when professionals, programs and an entire “healthcare”/treatment industry base their system on these principles; we have a major problem on our hands.

10% Engagement

We have the type of problem that leads to only 10% engagement of people in need, 73,000 per year dead of overdose and 88,000 per year dead as a direct result of chronic alcohol misuse.

Standard operating principles such as administrative discharge, labels of treatment resistant, labels of the family as enablers, and termination from therapy groups for displaying symptoms of the disease (ie..relapse), clearly indicate that the industry is beholden to these misguided assumptions.

Rock bottom and willingness are myths and fortunately more people than ever are challenging these ideas.

I guess that is what happens when 73,000 people die of overdose every year.

No Research

We start questioning concepts that have never before been challenged. There is no research that supports the legitimacy of hitting bottom as a helpful construct, at least in terms of outcomes.

I’m not sure there is a more important outcome than staying alive and we know that rock bottom directly contributes to increased deaths. Especially in this age of fentanyl and carfentanyl.

In addition, the necessity of willingness as a pre-requisite for successful treatment has been completely deconstructed by motivational interviewing.

Interestingly, despite the widespread adoption of motivational interviewing in the addiction field, providers do not actually practice motivational principles.

Cookie-Cutter Treatment

For example, kicking someone out of a therapy group for using or out of a residential program for “non-compliance” is 100% antithetical to motivational principles.

Cookie cutter after-care plans demanding 12-step attendance and involvement in intensive outpatient programs do not reflect individualized client-center programming.

In addition, encouraging the family to “get out of the way” and wait for bottom remains the default setting where family support is concerned.

Baffling

This baffling reality begs at least three questions:

• How did these practices become the industry standard?

• Why is this (clearly inappropriate outlook) still the prevailing attitude?

• What other options are available for the individual and/or family looking for support?

How Did We Get Here?

Understanding the origin of “rock bottom” and “willingness”.

It is nearly impossible to trace the origin of rock bottom, or any slogan for that matter.

As previously mentioned, this concept was never meant to guide the healthcare (treatment) policies of any entire nation. It was a slogan that served a purpose within the confines of a self-help group.

We can, however, make some universally agreed upon assumptions that will help us understand how we got here.

Alcoholics Anonymous

Everyone agrees that the recovery slogan “rock bottom” or “hit bottom” (as it relates to addiction) originated in the rooms of Alcoholics Anonymous. The Alcoholics Anonymous 12 & 12 (12 Steps and 12 Traditions) published in 1953 stated:

1. “Why all this insistence that every A.A. must hit bottom first? The answer is that few people will sincerely try to practice the AA program unless they have hit bottom.” 12&12, p. 24
   Willingness, as applied to addiction recovery, was present in the AA literature right from the very start as well:
2. “If you have decided you want what we have and are willing to go to any length to get it – then you are ready to take certain steps” BB, p. 58.

I would like to point out that the 12 & 12 clearly states – “few people will sincerely try to practice the AA PROGRAM unless they have hit bottom”.

In addition, the Big Book said – “if you want what we have to offer (i.e. the AA program) and are willing ….”

Not The Only Way

The 12 & 12 doesn’t say that few people will sincerely try to get recovery unless they hit bottom, or few people will sincerely attempt treatment unless they hit bottom, or few people will sincerely try to get healthier unless they hit bottom.

The focus is on what is required for AA and AA is NOT the only way to recover.

We do not have to debate that do we?

If you object comment below and I will get you the quotes from Bill Wilson himself on multiple pathways to recovery. I will also get you the research on pathways to recovery.

The Big Book does NOT say if you want to get some help you have to be willing.

It does NOT say if you want to see a professional addiction specialist or receive medicine you have to be willing to go to any length.

Again, the Big Book was talking ONLY about the program of Alcoholics Anonymous.

These concepts, in their original intent, were 100% applicable to AA only!

Professionalization

The problem was, and still is, the professionalization of the 12 steps and the co-opting of a self-help program via the treatment industry.

Essentially, a violation of the 8th tradition: “Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers”.

This is the great tragedy of the recovery revolution.

Perhaps then, the real question is:

“How did the treatment industry get away with professionalizing the 12-steps and other AA principles”?

We do not have the bandwidth in this blog post to provide a comprehensive review of the treatment industry in America.

There are many people who are much more qualified than I am to provide such a historical exposition.

For reference and verification of what I talk about below please see the following:

• William White Slaying the Dragon;

• Miller and Carol Rethinking Substance Abuse:
• What the Science Shows and What We Should Do About It;

• and Jerry Spicer The Minnesota Model.

Furthermore, most of this my opinion and my theory. It is logical and makes sense but at the end of the day it is one person’s take on how we got here.

It Works If You Work It?

What follows is a very crude summary of “how we got here”:

1) Alcoholics Anonymous works (if you work it). We have no idea about the recovery rates pre-AA and we have no idea about the recovery rates outside of AA post launch and we see much debate surrounding the recovery rates associated with AA right now.

However it is clear, that AA provided the first tangible program of hope and recovery for many hopeless alcoholics.

It was the first “program” that grew and it was certainly the first program with a “book or manual”.

Published April 10, 1939

The Big Book was published April 10, 1939 and is one of the most influential and important books of the 20th century. It could be argued that it is one of the most important books of all time.

2) The Stigma-Part 1: People with substance use disorder, regardless of the substance, are very difficult to deal with and in the mid 20th century the stigma was much stronger than it is today.

As time went by, Alcoholics Anonymous represented the only substantial group of people willing to work with those suffering with alcohol use disorder (and other addictions).

As the need for more formal “treatment” emerged Alcoholics Anonymous members were the ONLY ONES WILLING TO WORK WITH THIS STIGMATIZED GROUP.

Therefore, it was natural that the principles of AA were brought along for the ride.

3) The Minnesota Model: In 1948-1950 Hazleden Foundation.

The Minnesota Model

Pioneer House and Wilmer State Hospital in Minnesota develop a professionalized, multi-disciplinary team approach to “treating” addiction. It is aptly named, the Minnesota Model.

The model is founded on AA principles combined with medical staff and eventually professional counseling. However, it is naïve to think that AA principles did not guide the process.

Imagine a “non-recovering” doctor arriving to work in a Minnesota Model program.

The patients were probably a challenging group and the AA model probably held things together.

AA members were fully conditioned to believe that their way was the only way. For non-recovering staff it was either assimilate or move on. This was not really an interdisciplinary model as much as it was an AA model with some medical and psychological consultation. But more on that in a moment.

Notably: on an anecdotal level these programs work.

For the first time ever there is hope and a method to the madness of dealing with an active alcohol use disorder.

28 Days

The Minnesota Model is a great way to kick-start the treatment industry.

However, it is problematic to underestimate the primacy of Alcoholics Anonymous in the model and it become mores difficult to reconcile this reality in relation to a healthcare issue.

This model eventually becomes the 28-day inpatient rehab program reimbursed by health insurance and expands rapidly across the nation.

It becomes the “default setting” for addiction treatment.

The National Center for Biotech Information (NCBI) put it this way: “For many years, some in the treatment field considered the Minnesota model the only “workable” method of treatment for substance use disorders”.

I would argue that most professionals in the treatment field continue to think this way and that the AA/12-step principles are still the cornerstone of most programs.

4) The Stigma Part 2: Since the “general public” views addiction as a moral failing there is little interest or pressure for the delivery of addiction treatment services to be studied and evaluated. “Who cares what happens to those wretched addicts and alcoholics; they did it to themselves”.

The Minnesota Model carried on unencumbered by oversight or research, relatively speaking.

Unproven Practices

For decades these unproven practices plows deeper and deeper into the collective conscious of the industry. Before long even the non-recovering staff are converted.

5) Professionalization fails to produce diversity in treatment approaches:

The 1970’s and 1980’s saw the movement away from hiring recovering people toward the employment of licensed professionals.

This is not necessarily a positive step in and of itself, however, one the logical results should have been a de-emphasis on the one-size fits all model. If you have less AA members or NA members being employed you would naturally assume a retreat from some of the ingrained practices.

This did NOT happen. Mainly, because the administration and leaders in the industry had come up in the Minnesota Model and remained committed to that approach.

6) Hazleden starts selling books and positions itself as the nation’s expert:

William White

According to William White:

“In 1954, Hazelden entered the world of publishing when it bought the rights to Twenty-Four Hours a Day, a recovery meditation book that would go on to sell more than seven million copies. Hazelden went on to publish materials ranging from scholarly texts such as Not-God: A History of Alcoholics Anonymous by Ernest Kurtz, to popular self-help books such as Melanie Beatties Codependent No More. Hazelden publishing grew from this single title to a division that today distributes more than three and one half million books, pamphlets, videos, and recovery celebration items per year”.

Naturally, the emphasis from one of the founders of the Minnesota Model will be on Minnesota Model type programs. Abstinence-based and 12-step oriented.

7) The 12-step foundation is useful for after care and a synergistic relationship has been formed with AA world service: The 12-steps hang in nearly every treatment center in America.

The Backbone

They form the backbone of the daily schedule for many inpatient programs and they form the core of most after-care plans.

These treatment centers receive reimbursement for professional services.

How is this NOT violation of the 8th tradition and why has AA world service never pushed back? Simple, rehabs fill the rooms of AA. It’s a mutually beneficial relationship.

I also assume there is literally nothing AA can do about this practice.

How could they stop it even if they wanted to?

Treatment Culture

This all adds up to a treatment culture that primarily reflects the values, traditions, mores and norms of Alcoholics Anonymous.

This is clearly inappropriate and does not reflect a practice consistent with evidenced based healthcare.

Then again, there are many things about other aspects of healthcare that is problematic, this is just addiction treatment’s most obvious issue.

Since the values and norms of the “rooms” also carry the day in the treatment space; slogans like “hitting bottom” and “willingness” drive everyday policies and procedures.

This is how we got here.

The post The Myths Of Rock Bottom and Willingness—Part 1: appeared first on The Recovery Cartel.

FAVOR Greenville champions all Pathways to Recovery.  This includes 12-step recovery meetings.  We believe the fellowships of Alcoholics Anonymous and Narcotics Anonymous are a first option for many of our participants.  In nearly all cases it is the first outside resource discussed via recovery planning.  If people are willing, we run with the plan for meeting attendance.  However, we do not believe that recovery is a one size fits all process and there are many ways to find recovery.  All of these are worthy of celebration.  We just want to see your life get better.

Therefore, when we shine light on one size fits all treatment, we are not doing so in reference to AA or NA.  We are doing so in reference to the professionalization of 12-step recovery and a private system that, in many cases, denies the patient access or information regarding alternative pathways of recovery.  With that in mind I wanted to put forth some random thoughts on multiple pathways.

1) Multiple Pathways Exist: Perhaps the most controversial thought concerns the fundamental reality that multiple pathways of recovery exist.  Because of the stigma and shame surrounding addiction relatively little research has been done on recovery.  Our culture, as a whole, considers addiction a “moral failing” so there is little demand or interest in gaining scientific insight into the recovery process.  In addition, many professionals in the field have little concern with research on recovery.  Especially if they have had their own personal experience in recovery.  This leaves a void of knowledge which has, unfortunately, been filled with clichés and conventional wisdom.  To paraphrase Randy Gage and his new book Mad Genius: this void has allowed the mysterious people in charge of the secret system that runs (addiction treatment) to simply proclaim there is only one way to recover.  I don’t know how many individual people believe this.  It is a very difficult thing to assert and still consider yourself a rational person.  However, the herd mentality frequently kicks in and people jump on board with this type of claim even in the face of evidence to the contrary.      

This void has allowed the mysterious people in charge of the secret system that runs addiction treatment to simply proclaim there is only one way to recover.  No one knows who these people are.  They are the ones who established all the things that have “always been done this way” (adapted from Randy Gage, Mad Genius). 

Typically, the pathway most commonly promoted is 12-step recovery found in Alcoholics Anonymous or Narcotics Anonymous.  AA and NA are the most well-known pathways and many have found recovery through these programs.  In fact, they are the most common “formal” pathway of recovery.  My concern has nothing to do with the programs of AA or NA.  My concern is with the professionalization of AA and NA.    I have heard professional counselors proclaim that AA is the only way to find recovery.  I have heard stories of patients being required to complete steps while in facilities that claim to be licensed inpatient rehabilitation facilities.  This is a big problem.  If you find yourself in the presence of a therapist who says something along the lines of “you must do AA in order to recovery” you should look around for other options.  Insurance should not be paying for 12-step sponsorship.  The responsible thing, from a medical perspective, is to promote all pathways of recovery and develop aftercare plans that are truly individualized.

One of the problems with exploring pathways to recovery lies in the definition of recovery.  Does it mean complete abstinence?  Does it mean complete abstinence plus a defined program of self-improvement?  Does it mean complete abstinence plus a “spiritual awakening”?   Is mediation assisted treatment a viable pathway to recovery?  What about the reality of substance use disorder full remission?  In other words, a person had a substance related problem but no longer does.  These individuals may or may not use, either way they are no longer destroying their lives.  How do we characterize these individuals?  I think that is a good thing if their lives are improving.

When you explore substance use in a realistic manner you find much complexity and nuance.  If you are a self-help attendee, you have little responsibility beyond the black and white.  A person is in recovery if they do “the program”.   However, if you are a professional healthcare or treatment provider you have an ethical responsibility to explore all angles and gain a deeper understanding.   For the sake of research there has been a general agreement on recovery as “remission of symptoms”.  It is the most quantifiable variable and from a public health perspective the most important.

In addition to 12-step recovery, The Recovery Research Institute (RRI) out of Harvard lists the following as “clinical” pathways which have been proven effective:  pharmacology, Acceptance and Commitment Therapy, holistic based recovery services, Community Reinforcement Approach, CBT based approaches, Contingency Management, Relapse Prevention Therapy, Motivational Interviewing/MET techniques, 12-step Facilitation, Behavioral Couples Therapy, and Family Therapy.  Among “non-clinical” alternative services you find: Recovery Community Centers, Peer-Based Recovery Support, Education Based Recovery Support, Employment Based Recovery Support, and Faith-Based Recovery Support.  Furthermore, alternative mutual support groups existing including: SMART Recovery, Rational Recovery, Women For Sobriety, HIP Sobriety, LifeRing, Secular Recovery Organizations and many others.

In addition, some achieve recovery or “remission” without any formal help.  From the RRI:

“Some individuals can achieve substance use disorder remission without formal help from professional treatment or mutual-help organization participation”.

Again, because of the mysterious people in charge of the secret system that runs addiction treatment we have allowed our professional systems to ignore these facts.  Even Bill Wilson knew there were many ways to recover.  The following are all quotes from the esteemed Mr. Wilson:

–“AA has no monopoly on reviving alcoholics.”

–“The roads to recovery are many… any story or theory of recovery from one who has trod the highway is bound to contain much truth.”

–“Upon therapy for the alcoholic himself, we surely have no monopoly.”

–“In no circumstances should members feel that Alcoholics Anonymous is the know-all and do-all of alcoholism.”

Professional organizations, counselors and addiction treatment centers should be held accountable to standards that include a full menu of recovery options.  Are we not “withholding” possible solutions when we discuss only 12-step recovery?  This seems like an advocacy issue that those of us in the recovery management movement should take on.

2) It is likely that “new” pathways will be invented: As we often hear in the rooms of recovery, recognizing and accepting the problem is the first step. If we are in denial of the problem we can never find a solution.  If we are unable or unwilling to look at the situation from a reality based perspective, we will never make a change.

I would argue we are in denial regarding this issue.  90% of the treatment programs in America operate from the same fundamental philosophy, and it is not working.  As it currently stands only 10% of those in need are engaged in services.  It is logical to assume that some of this is the result of a one size fits all approach.  If we opened the door wider more people would walk into the recovery process.  If we offer alternatives and programs that meet people where they are you will see improved engagement.

I also believe there is a shelf life on the current approach.  I do not think this business model is sustainable and people will start to differentiate.  Marketing programs that are all identical will not be effective as you get a more educated and knowledgeable patient base.

And I believe that as soon as we acknowledge the problem we will innovate and develop new solutions.  It is already happening in small pockets around the country.  Including Greenville, South Carolina.  We will develop alternatives that we cannot even envision right now.  Technology will help.  However, I believe the real break-through will occur when we educate, train and supervise a new workforce.  One that emphasizes engagement and connection over dogma and acute care rinse and repeat models.

We will realize that “the way we have always done things” makes no sense.  We will rise up and challenge the mysterious people in charge of the secret system that run the addiction treatment system and develop new protocols, payment systems, and norms.  We will develop an entirely new culture of professional recovery services.  Twenty years from now people will look back on this day and time as the transformation point.  They will wonder why it took so long to make changes.

3) Co-Occurring Recovery will be one of the new pathways: Double trouble or dual diagnosis groups have always existed.  However, they are few and far between and they are not available for many in need.  We know that upwards of 60% of those with a substance use disorder also suffer from some type of mental health issue.  The days of mental health issues being cleaned up via the natural progression of recovery are over.  We can no longer just wait for the person to sober up and see if the depression goes away.  Some studies indicate trauma is present in up to 80% of women in recovery.  Trauma symptoms can be made worse if mishandled and there will be a need for specialized support in these areas.  This is all good stuff.  We have advanced as a society.  We are more informed and educated than we were in the past and our needs have changed.  That is not unusual.  It is predictable and healthy.

In addition, people with mental health issues sometimes struggle to fit into “regular recovery” groups.  Medication is one reason.  Social anxiety would be an example of another reason.  It is likely that new recovery groups will spring up to meet the needs of participants with co-occurring disorders.  At FAVOR Greenville, we are developing a curriculum that certifies a coach as a COD specialist.  This will be a positive development in the fight against addiction. 

4) Medication Assisted RECOVERY will be one of the new pathways: Despite the best efforts of many people in recovery, many people on medication assisted treatment have felt alienated from recovery rooms.  I have no interest in entering into that debate in this blog post.  It would require much more time than I have at the current moment.  Suffice to say, there is likely to coalesce a specific recovery program for people on medication replacement therapy.  A place where they can talk and share openly on all matters including the use of Suboxone or Methadone.  We know this is a very contentious subject in some recovery rooms.  At FAVOR Greenville, we welcome you into the recovery process no matter what stage you are in.  We want you to keep coming back.  Medication assisted or not.  I believe we will see more specific programming and services related to medication assisted recovery.  We know community is exceedingly important to the recovery process and it is going to be necessary to address this glaring issue as we move forward.

In closing I want to reiterate.  At FAVOR Greenville, we are big fans of 12-step recovery.  However, we are also big fans of SMART recovery, Women For Sobriety, FAVOR primary recovery, clinical recovery, medication assisted recovery, and any other recovery you can think of.  Our interest is in seeing your life improve.

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