“The world is nothing but change. Our life is only perception.” – Marcus Aurelius (850/2003)
The world seems to change at a faster and faster pace. For instance, how many of us keep up enough to say we are “tech savvy?”
The world of addiction, treatment, and recovery is changing as well, including the increased use of the self-empowering approach (e.g., SMART Recovery); substitution medications (e.g, buprenorphine/Suboxone for opiates); preventive medications (e.g., naltrexone/Vivitrol for opiates, disulfiram/Antabuse for alcohol); electronic monitoring devices (e.g,, SCRAM, Soberlink); online mutual help groups (e.g., IntheRooms.com); online treatment (e.g., Lion Rock Recovery) and assessment (e.g., CheckupandChoices.com); moderation and harm reduction approaches; and natural recovery as the broad framework for understanding the recovery process.
How much do we accept these changes? I suggest that it is now time for responsible addiction treatment professionals, when engaged in assessment, treatment planning, and making referrals, to
- have basic awareness about these and ongoing innovations (to the extent an innovation has an adequate scientific foundation)
- recommend them as suitable options for some individuals
- recognize that Twelve Step and disease model approaches are also suitable options for some individuals
- refrain from advocating for any particular approach
- help clients explore these options, so they can make informed decisions about how to change
- encourage progress (not perfection) by informing clients that success or at least substantial progress is ultimately likely for most
There remains a role for professionals who take only one approach (e.g., a Twelve Step approach), provided they refrain from the broader role of assessment, treatment planning and referral. These professionals might say,
We recognize in the recovery field that there are multiple pathways to recovery. I specialize in the Twelve Step approach. I’m not familiar enough with other pathways to help you decide about them. If you want an assessment specifically for the services we offer, I’m happy to provide it. Otherwise I can refer you to a primary care addiction provider, a generalist who can help you make basic decisions about moving forward. It’s possible that, having explored all your options, you’ll still end up back here. If so, I look forward to working with you. Our Twelve Step approach is very helpful to the clients who choose it, but of course no approach works for everyone. Whatever you choose, I encourage you to be persistent in your efforts and patient about your progress. In time, almost everyone is successful in resolving addiction problems, or at least substantially improving them, even if the process is rocky at times.
The Surgeon General’s Perspective
How valid is the idea of multiple pathways? “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” released in November 2016, states, “The diversity in pathways to recovery has sometimes provoked debate about the value of some pathways over others” (HHS, 2016, p. 5-4).
I suggest that the Surgeon General would like to end that debate. As Kana Enomoto, principal deputy administrator at the Substance Abuse and Mental Health Services Administration (SAMHSA), writes in her Foreword, the Report “provides a roadmap for working together to move our efforts forward” (HHS, 2016, p. iii). Will we do so? Consider the following statements from that Report.
- “Substance use disorder treatment is designed to help individuals stop or reduce harmful substance misuse, improve their health and social function, and manage their risk for relapse” (HHS, 2016, p. 4-3).
- “The goals of early intervention are to reduce the harms associated with substance misuse” (HHS, 2016, p. 4-5).
- “Harm reduction programs provide public health-oriented, evidence-based, and cost-effective services to prevent and reduce substance-use-related risks among those actively using substances, and substantial evidence supports their effectiveness” (HHS, 2016; p. 4-10).
- “Treatment plans should be personalized and include engagement and retention strategies to promote participation, motivation, and adherence to the plan” (HHS, 2016, p. 4-17).
- “All substance use disorder treatment programs are expected to offer an individualized set of evidence-based clinical components” (HHS, 2016, p. 4-19).
Medication-Assisted Treatment (MAT)
- “MAT [medication-assisted treatment] for patients with a chronic opioid use disorder must be delivered for an adequate duration in order to be effective. Patients who receive MAT for fewer than ninety days have not shown improved outcomes. One study suggested that individuals who receive MAT for fewer than three years are more likely to relapse than those who are in treatment for three or more years” (HHS, 2016, p. 4-21).
- “The research clearly demonstrates that MAT leads to better treatment outcomes compared to behavioral treatments alone. Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion” (HHS, 2016, p. 4-22).
Mutual Aid Groups
- “Given the common group and social orientation and the similar therapeutic factors operating across different mutual aid groups, participation in mutual aid groups other than AA might confer similar benefits at analogous levels of attendance” (HHS, 2016, p. 4-30).
Personal Views and Stigma
“Some people who have had severe substance use disorders in the past but no longer meet criteria for a substance use disorder do not think of themselves as operating from a recovery perspective or consider themselves part of a recovery movement” (HHS, 2016, p. 5-4).
“In the general population, many people who once met diagnostic criteria for low-severity, ‘mild’ substance use disorders but who later drink or use drugs without related problems do not define themselves as being in recovery” (HHS, 2016, p. 5-5).
“Despite negative stereotypes of ‘hopeless addicts,’ rigorous follow-up studies of treated adult populations, who tend to have the most chronic and severe disorders, show more than 50 percent achieving sustained remission, defined as remission that lasted for at least one year” (HHS, 2016, p. 5-6).
The Surgeon General’s report also contains significant criticisms of the addiction treatment field:
- “Well-supported scientific evidence shows that behavioral therapies can be effective in treating substance use disorders, but most evidence-based behavioral therapies are often implemented with limited fidelity and are under-used” (HHS, 2016, p. 4-2).
- “For evidence-based behavioral therapies to be delivered appropriately, they must be provided by qualified, trained providers. Despite this, many counselors and therapists working in substance use disorder treatment programs have not been trained to provide evidence-based behavioral therapies, and general group counseling remains the major form of behavioral intervention available in most treatment programs. Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems” (HHS, 2016, p. 4-26).
- “Group counseling is a standard part of most substance use disorder treatments, but should primarily be used only in conjunction with individual counseling or other forms of individual therapy” (HHS, 2016, p. 4-26).
- Personalized care [emphasis added] is not common in the substance use disorder field because many prevention, treatment, and recovery regimens were created as standardized “programs,” rather than individualized protocols (HHS, 2016, p. 1-24).
If we are interested in moving our professional practices to the level of personalized care, then, among other topics, we will need to know about the self-empowering approach, which is the primary focus of this article. With even broader knowledge, we can work as generalists; that is, primary care addiction providers who can conduct assessments, treatment planning, and referrals that are not limited to a specific set of services.
Although the Surgeon General’s report is highly authoritative and recent, there have been other authoritative calls to action as well, and not just recently. One of the most significant was “Broadening the Base of Treatment for Alcohol Problems” (IOM, 1990). Unfortunately, many of the changes called for in that document are still needed. The Recovery Bill of Rights (Faces and Voices of Recovery, n.d.) is a more recent and pithier example.
Stanton Peele presents a brilliant analysis of the shortcomings of the Surgeon General’s Report, from the perspective of the changes the recovery field ultimately needs to make (2016). From my perspective, the Surgeon General’s Report occupies middle ground between how the field operates now and where it ultimately needs to be. I view the Report as a realistic plan for change at present.
The Self-Empowering Approach
“Self-Empowering” is a term emphasizing the perspective that the solution to addiction resides within individuals, rather than outside of them such as in a higher power, group or Twelve Step sponsor. The language of the alternative perspective, powerlessness, is clearly described in AA’s first three steps (Alcoholics Anonymous World Services, 2001, p. 59):
- We admitted we were powerless over alcohol—that our lives had become unmanageable.
- We came to believe that a Power greater than ourselves could restore us to sanity.
- We made a decision to turn our will and our lives over to God as we understood him.
Another interpretation of “self-empowering” can be gathered from the Serenity Prayer: “God grant me serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference” (“The origin,” 1992).
From this perspective the self-empowering approach is primarily a courage approach, rather than a serenity approach. Clients are encouraged to identify and resolve issues necessary for establishing successful recovery, including
- identifying and maintaining motivations to change
- coping with craving and other impulses
- identifying and addressing problems (e.g., depression, anxiety, bipolar disorder, etc.) that often establish a foundation on which addiction flourishes
- achieving greater lifestyle balance as way to prevent a recurrence of problems
- improving relationships, as they are ultimately more satisfying than intoxication
- living with meaning and purpose, which is also ultimately more satisfying over time than intoxication
Mutual Aid Groups
The self-empowering approach is available in treatment and in mutual aid groups. The mutual aid groups include SMART Recovery, Women for Sobriety, Lifering Secular Recovery, Refuge Recovery, Secular Organizations for Sobriety, Moderation Management, and HAMS Network (listed here in approximate order of size). Listing these groups together, because they are not powerlessness-based, does not mean to imply that significant differences between them do not exist. However, these differences are beyond the scope of this article.
SMART Recovery, the largest of these groups, has over two thousand meetings worldwide, printed materials in eight languages, and affiliate organizations in the UK and Australia (Horvath & Yeterian, 2012). SMART’s tools for recovery would be familiar to anyone familiar with cognitive behavioral and motivational interviewing ideas and techniques. SMART has numerous tools, including ones for identifying and modifying dysfunctional thinking and belief, coping with craving, identifying motivations to change, breaking large change into small steps, and accepting oneself even while not accepting some past or current behaviors.
I suggest that responsible addiction professionals identify which of these organizations operates in their locality, survey each organization’s national or local website, perhaps attends a meeting, and have information about these organizations to provide to clients (such as the website) so that clients can investigate further.
Similarly, responsible professionals also identify the self-empowering treatment in their own locality. The Self-Empowering Addiction Treatment Association (www.seatainfo.org), along with the websites of the self-empowering groups (which often list treatment resources) are the places to start that search. Unfortunately, treatment may be even less available than these mutual aid groups. If intensive treatment—residential or intensive outpatient—is indicated, it may need to be obtained out of area.
How to Introduce Multiple Pathways
The introduction of self-empowering mutual aid needs to occur in a larger context. Imagine that willing individuals, perhaps accompanied by family, have come in for an assessment and recommendations for substance problems. We will later consider the same situation if these individuals have been substantially coerced to attend the evaluation and are in “denial.”
After the evaluation portion of the interview is completed, the recommendations section might occur as follows:
Thanks. We’ve discussed what’s been problematic for you with your substance use, and your desire to make changes. Now let’s consider the options you have, starting with the free and low-cost ones. Then we’ll move on to what treatments you might want to access. Treatment, of course, isn’t free, so we’ll need to consider options that fit your budget. Ideally treatment would be available without budget considerations, but the US hasn’t reached that level yet. First we’ll discuss mutual aid groups, then treatment, and lastly all of the other changes you might make in your life, even if you don’t get involved with either mutual aid or treatment.
Mutual aid groups are also known as support groups, self-help groups, or mutual help groups. They’re free, but donations are requested. They bring together individuals in various phases of the change process. Together they study the recovery approach used by that group. Some individuals, like you, are relatively new. Others may have years or decades of experience.
These groups aren’t treatment. Treatment involves working with professionals, establishing a treatment plan, monitoring progress, and often working with your insurance company. The treatment provider may have very specific recommendations for you. Treatment is typically time limited, whereas attendance in mutual aid groups is open-ended and can last a lifetime.
Far and away the most widely available type of mutual aid groups are those based on the Twelve Steps of Alcoholics Anonymous (AA). There are dozens of related organizations such as Narcotics Anonymous (NA) or Cocaine Anonymous (CA). If you find these groups helpful, you get the benefit of having the largest network of meetings available to you. Originally established in 1935, these groups have a long tradition around the world. They are well-known and widely respected. They are so well established that they offer an entire nonusing social world for you to enter, if you wish to do so. In particular the Twelve Step groups offer the option of having a sponsor, a one-to-one relationship with an experienced person in recovery who will assist you in learning the Twelve Step approach. Of course, it’s up to you how involved you get with any group.
By the way, if you call your sponsor in the middle of the night because you have a strong craving, your sponsor will probably be glad you called. Your treatment provider may be glad to hear from you then as well, but maybe not, and either way the provider will probably charge you!
There are other approaches to recovery that are quite different than the Twelve Step approach. Described on the surface, the Twelve Step approach involves accepting the idea that individual willpower will not be sufficient to resolve your problems, whereas the self-empowering groups involve building up, over time, your willpower and personal capacity to recover. The self-empowering groups often go to significant effort to teach you various ideas, techniques, and tools for recovery.
However, this surface description doesn’t include the reality that there are as many ways to participate in these groups as there are individuals. We don’t yet know how you specifically might make use of these groups, or whether you’ll attend at all. How you experience them will be unique to you. Another wrinkle is that you might end up attending multiple mutual aid groups, even if on the surface they seem to have vastly different perspectives. There are as many ways to recover as there are individuals. The job for the two of us, as long as we’re working together, and your job ultimately, is to find out what works for you.
I’ll give you some additional aspects of these two approaches, but ultimately the best way to assess them is probably to attend one or more meetings of each. We can discuss what you observe if you wish. Typically the self-empowering groups don’t have sponsors, don’t expect lifetime attendance, have meetings that are more conversational, have a large array of tools and techniques to consider, and may be more flexible about abstinence versus moderation goals. The Twelve Step groups do have sponsors, encourage long-term or lifetime attendance, have meetings that are less interactive, have less emphasis on tools and techniques, and are generally clear that the requirement for membership is a desire to stop.
Another way to describe the differences between these groups is to compare them to two courses of study you might sign up for in school. Imagine one course has no electives. Once you sign up, they tell you what to study; AA is more like that. The self-empowering groups are more like choosing a broad field of study then choosing one elective after another. Some people like to make one big decision at the beginning, and be closely guided thereafter. Others may be more comfortable making many smaller decisions along the way. SMART Recovery, the largest of the self-empowering groups, has a slogan that emphasizes ongoing decision-making: “Discover the power of choice.”
However, some individuals don’t attend mutual aid groups at all. Although the groups are free, easily accessible, and attendance in them is associated with success, attendance isn’t essential for success. There are as many roads to recovery as there are individuals. Similarly, treatment is associated with success, but may not be essential for success. What’s most important is for you to be committed to change, and to be persistent even if you have setbacks.
One somewhat unexpected pathway to recovery is the individual who attends both Twelve Step groups and self-empowering groups (Horvath, 2014; White & Kelly, 2014). A common experience they report is, “I do Twelve Step for the fellowship and the other group for the tools.” I’ll be curious to hear what your experience is if you do that.
As I also said, that distinction between powerlessness and self-empowerment doesn’t cover all the relevant aspects of these choices. By making progress in recovery you’re going to feel empowered, almost no matter what approach you take. Similarly, even if you don’t think of yourself as powerless, you may identify realities that you need to accept rather than fight against. In attending these groups it may be most important to find the groups of people you connect with, whatever the approach of the group is. Building a new social network is very important (Kelly, Stout, Greene, & Slaymaker, 2014).
Now let’s move ahead and talk about treatment options.
There is a small but active community of treatment professionals who would largely agree with the phrasing of the above paragraphs. Most of them would identify themselves as harm reduction oriented. Although some vociferously oppose even the existence of Twelve Step groups, most are happy to work with the Twelve Step community if cooperation is reciprocated.
Other Significant Aspects of Self-Empowering Groups
Lack of Meetings
A major concern about self-empowering groups is the lack of meetings in most localities. Fortunately, most groups have a substantial online presence, either with meetings or with chat rooms and message boards. Treatment professionals dedicated to the concept of multiple pathways could establish self-empowering groups in their own communities, then assist them in becoming self-sufficient. Such affirmative action may be necessary if these groups are to become sufficiently available. Affirmative action by local, state, and federal governments is also worth considering.
When AA began, it entered a vacuum. Prohibition ended in 1933, AA began in 1935 (Alcoholics Anonymous World Services, 2017). There was very little treatment or any other service available. The oldest self-empowering group on the list began in the 1970s with Women for Sobriety (WFS, 2011). It entered a crowded marketplace, and one often hostile to its presence, hence the need for this article and many others like it. However, all mutual help groups would benefit from a wide array of groups. When that array is fully available and fully recognized, participants in any group will know they are present by choice, not because that group is the “only option.”
Most self-empowering groups sign court cards, but probably would be willing to stop the practice if Twelve Step groups did. A self-empowered approach to recovery is not consistent with coerced attendance.
Multiple Pathways or Individual Pathways?
The term “multiple pathways” may not adequately convey the complexity of the recovery process across a wide range of people. As Bill White states,
The addiction recovery experience has been sliced and diced in all manner of categories: secular, spiritual, and religious; natural recovery, peer-assisted, and treatment-assisted; and abstinence-based, moderation-based, and medication-assisted, to name just a few. Recovery achieved through any of these frameworks is often referred to as a pathway of recovery. The growing consensus that there are multiple pathways of long-term addiction recovery marks an important public and professional milestone within the alcohol and drug problems arena.
Progress has been made by recovery-focused research scientists on mapping recovery pathways and noting their distinctive and shared qualities. This classification work is important as long as one does not lose sight of the fact that reality is often far messier than such pristine categories would suggest. Or put another way, “the recovery map does not always accurately depict the territory” (2016).
Consequently, addiction professionals need to stay closely attuned to the specific individuals in the recovery process, and not attempt to push them into any previously established recovery path.
The self-empowering groups have attracted a significant number of individuals who either dislike AA or actively hate it. They are often not shy about expressing their contempt in meetings. Although it is the responsibility of the meeting manager to end these tirades, not all managers are adept at ending them quickly enough. For now, each mutual aid group, including Twelve Step ones, need to become better at staying focused on what they do, not on other approaches some participants do not like. Ideally each group would say, “no approach works for everyone; let’s stay focused on what we do here, then you can make your own decision about how helpful it is.”
The Language of Recovery
The concepts and language used in self-empowering groups may sound foreign to someone with a Twelve Step background. The Surgeon General’s report (HHS, 2016), the DSM-5 (APA, 2013), the Recovery Bill of Rights (Faces and Voices of Recovery, n.d.), and anything written by Bill White provide good examples of contemporary, science-based language about recovery, a term which itself may be outgrown in time.
What if the “Alcoholic” is in “Denial?”
I previously stated we would return to the situation of people coerced into a substance use evaluation. The “denial” that can occur there is often a result not of denying the facts of what happened, but instead denying the description of the facts or the suggested action steps arising from them. For instance, after a review of the presenting situation, professionals might state, “You need to admit you are an alcoholic, go off to rehab for at least thirty days, never drink again, and attend AA meetings for the rest of your life.”
Or these professionals might say,
The two of you disagree about some facts, but do agree that there have been several problems resulting from drinking. Now the question is what, if anything, to do about this situation, and what you [the nondrinker] will do if, from your perspective, sufficient progress doesn’t occur. Let me discuss some options for you to consider. Second, we’re going to talk about your [the nondrinker’s] options if you lose confidence that change isn’t happening or isn’t happening fast enough, but first we’re going to talk about your [the drinker’s] options for change. [Now insert the paragraphs from the section above on how to introduce multiple pathways].
The least irritating language to use is the language of the substance user, and the most likely course of action is the one the user suggests or at least agrees to. The presence of family, which often has substantial capacity to influence the user, means that change (or lack of) can be responded to. As opposed to having an intervention—a course of action that has a place in selected instances—many families would benefit from Community Reinforcement and Family Training (CRAFT; Smith & Meyers, 2007), an evidence-based, noncoercive, and highly effective approach for motivating a substance user to enter treatment. Unfortunately, even though CRAFT appears to be substantially more effective than interventions in getting identified patients into treatment, it is not well known, perhaps because it is not dramatic—it typically spans a course of ten to twelve sessions—and does not have its own television show.
Fields change by changing their concepts and their language. These changes involve reasoned discussion, heated debate or worse. This article aims to be a contribution to reasoned discussion.
If you are ready to practice in the manner the Surgeon General is indicating in his Report, this article has suggested specific language to use and specific actions to take, with particular focus on referring to and cooperating with self-empowering mutual aid groups like SMART Recovery. These groups have been in existence for thirty years and are apparently here to stay. I suggest that it is time that professionals who help others resolve or reduce problematic addictive behavior learn how to work with self-empowering mutual aid groups, or state openly that their practices are delimited to a specialty area. Individuals seeking comprehensive evaluation and treatment planning can seek these services from primary care addiction generalists, who take on the responsibility of staying abreast of developments in the entire field.
The world is nothing but change. Our life is only perception. Do you accept self-empowering recovery?
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