Executive Director’s Column
Think of any Hollywood movie you’ve seen
about addiction treatment: 28 Days with Sandra Bullock, Clean &
Sober with Michael Keaton, When a Man Loves a Woman with Meg Ryan
and Andy Garcia. The alcohol or drug addict shuffles off to treatment
where he or she attends group therapy, deals with emotional issues,
and participates in AA meetings. The characters struggle mightily
with their cravings. The background music rises dramatically and
the atmosphere turns tense as they fight the spell of the witch’s
brew. One character seems particularly overwhelmed. We cheer her
on, urging her not to falter; but, alas, the potion is too powerful,
and we feel a sadness as she succumbs and is kicked out of treatment
because of her weakness.
The public in Canada and the United States has
been educated (or, perhaps more accurately, ‘trained’)
to accept Hollywood’s version as the addict’s reality.
Professionals label this the ‘abstinence approach’,
which sees the recovering addict doomed to struggle throughout the
lifespan with the dagger of addiction looming over her head. According
to this approach, the defining feature of addiction is loss of control
over drug use, so insidious that even a single drink or drug plunges
the addict back into active addiction. The only hope is to stay
completely free of the narcotic draught.
versions that grew out of the 12-step program—have dominated
the treatment map across Canada and the United States. According
to Lemanski (2001), 12-step abstinence models form the basis for
96 percent of all treatments in America; Miller (1995) reported
that 95 percent of administrators in a national sample of treatment
providers said that their programs were based on 12-step programs.
As an aside, there are other non-professional
mutual aid societies in addition to the 12-step programs. Though
not heralded in the popular media, several abstinence-based mutual
aid programs have gained national attention. The most influential
have been Jack Trimpey’s Rational Recovery, its breakaway
program SMART Recovery, James Christopher’s Secular Organizations
for Sobriety/Save Our Selves (SOS), and Jean Kirkpatrick’s
Women for Sobriety. These programs advertise themselves as ‘secular’
alternatives to the 12-step program, dismissing Alcoholics Anonymous’
(AA) argument that addiction is a disease, that addicts are ‘powerless’
over their addiction, and that recovery demands a ‘God-consciousness’.
Each offers mutual support and provides a handful of cognitive-behavioral
strategies to prevent relapse. Like AA, however, they focus their
efforts on freedom from alcohol and drugs.
Influences on the Abstinence Approach
Many professionals accept that abstinence is
the only viable approach, and they reject any program that does
not demand abstinence. This is such an obvious truth for these disciples
that further thought is pointless. But if we take time to make their
implicit assumptions explicit, we can discern three forces that
drive their thinking: the traditional Minnesota Model, moral conviction,
and neurobiological reductionism.
Traditional Minnesota Model
No professional treatment has had the impact
of the traditional Minnesota Model. Originally developed by Wilmar
State Hospital, the Veterans Administration, and Hazelden Treatment
Center, all in Minnesota, the Minnesota Model is the cornerstone
of abstinence programs. When professionals and recovering addicts
were searching for a treatment to implement at Hazelden beginning
in 1949, they had a problem. The healthcare community at the time
was at a loss on what to do with ‘hopeless’ alcoholics.
Nothing they had tried had worked. But they did know that a fellow
by the name of Bill Wilson and his organization, Alcoholics Anonymous,
had some success reforming alcoholics, and they gratefully borrowed
his program. What would become known in the 1960s as the Minnesota
Model took the first five steps of AA and simply tacked on medical,
psychological, and, earlier on, religious components.
The model has evolved over the years, and many
service providers have variously modified it. Although it was originally
a residential treatment, outpatient versions of the model have now
been developed. (A manual-driven program intended for the individual
in outpatient settings is known as twelve-step facilitation (TSF)).
Although the model introduces clients to 12-step programs and offers
mainly cognitive-behavioral therapy, it relies on the 12-step program
as the agent of change. Clients are expected to attend AA or one
of its sibling programs after completing treatment. Today, researchers
interested in the step program, including fans of the Minnesota
Model, publish papers on the efficacy of AA’s ‘spiritual
principles’, such as forgiveness, gratitude, honesty, hope,
and humility, which are its claim to success (see, for eg, Forcehimes,
2004; Hart, 1999).
Unfortunately, many people have mistakenly equated
the Minnesota Model and AA. The two are, however, quite different.
Although it relies on 12-step programs for aftercare and as the
main change-agent, the model itself is the interpretation of professionals
on what the first five steps mean and how to work through them.
AA had focused on ‘spirituality’ to transform the addict;
professional treatment had more to do with unlocking family dysfunction,
dealing with issues such as depression and anger, and setting standards
of behavior. Spirituality was simply one more ‘issue’
to be worked through. A tour through the seemingly endless step
publications of these programs shows that few agree even on the
basics. But the one point they all agree on is that total abstinence
is the goal of treatment. Programs accept only those who are completely
free from drugs, and frequent testing is used to maintain the zero-tolerance
Minnesota Model and moral narrative
As in AA, the Minnesota Model sees addiction
as a disease, and many observers have linked it with Disease Model
of addiction. But many others have equated it with the moral narrative.
Originally, the moral perspective preached abstinence as the solution.
No professional treatment was needed, since redemption for inveterate
inebriates demanded that they either get on their knees and pray,
or simply ‘just say no’. In principle at least, prohibition
legislation in 1920 (1918 in Canada) obviated the need for any sort
of formal help.
After prohibition was repealed in 1933 and addiction
science was reborn, treatment again became a reasonable alternative
for the alcoholic. Today, religious organizations that operate treatment
facilities, such as the Salvation Army and Union Gospel Mission,
find the Minnesota Model appealing. The idea of turning to a higher
power is mentioned in three of the first five steps. And the model,
itself, emphasizes the moral defectiveness of addicts: step four
asks them to complete a “moral inventory.” The Minnesota
Model sees these ‘defects of character’ as part of the
addict’s personality, and therapists borrowed various Freudian
traits, especially denial and narcissism, to explain the addict’s
maladaptive behavior. Denial is a personality deficiency, a defense
mechanism that allows the addict to keep using drugs even though
his behavior damages himself, aggrieves his family, and afflicts
society. A person in denial does not even know he has a major problem.
Much of abstinence treatment is targeted at breaking through denial,
and the recommended counseling style is to confront the addict with
his depraved behavior. A typical technique invites family members
into a session to tell the addict how he has hurt them.
Narcissism is also a personality deficiency.
Harry Tiebout (1944), a Connecticut psychiatrist who was Bill Wilson’s
psychoanalyst for a time, described the alcoholic as “a narcissistic
egocentric core, dominated by feelings of omnipotence, intent on
maintaining at all costs its inner integrity” (p. 469). In
less Freudian terms, what Tiebout (1944) was commenting on was that
the most important relationship in the addict’s life is with
the drug, and the addict goes to any length to protect this relationship.
Lying and manipulation are common tactics. An old joke in abstinence
programs asks, ‘How do you know an addict is lying? Answer:
His lips are moving’. One residential treatment facility in
British Columbia wakes up clients in the morning with greetings
such as, ‘So what are you going to lie about today?’.
These defective personalities cannot be trusted to behave openly
Because addicts have pathological personality
traits, counselors take it upon themselves to control the client.
This idea is, in large part, borrowed from AA, which states that
the AA group will care for the alcoholic until the alcoholic learns
to care for himself. (The unspoken rule in AA is that anyone with
less than five years of sobriety is ‘early in recovery’.)
A behaviorist approach is essential for success. For instance, many
residential programs do not allow clients to leave the facility
unescorted. Abstinence programs usually include a rulebook of dos
and don’ts, because the addict, left to his own devices, would
simply lie and manipulate his way through the program, getting away
with whatever he can. Whatever one thinks of the excesses of James
Frey’s (2003) A Million Little Pieces, the book is a reasonably
accurate description of life in Hazelden Treatment Center in the
early 1990s. One might assume that a book on treatment would describe
the struggles of clients to come to terms with addiction, but most
of the book describes how to behave in the center according to its
thick rulebook. The rules, themselves, are basic and intended to
impart the habits of a healthy lifestyle: get up at a reasonable
hour, eat three healthy meals, do chores, show up for group punctually,
and so on. Therapy also includes learning healthy coping skills
to deal with stress, conflict, guilt, anger, and other issues. Behaviorist
theory states that if clients practice this lifestyle for four weeks,
then they will develop new healthy habits. Of course, clients who
refuse to follow these simple rules are, according to model, not
ready for treatment and discharged.
Abstinence-based programs thus focus on the
construct of ‘addiction’, in the same way that the old-style
physician focuses on ‘heart disease’ or on a ‘bone
fracture’ and not on the whole person. Addicts may come from
all walks of life, have different ways of thinking, and unique experiences,
but, in general, treatment for one is the treatment for all.
The focus of most programs is solely the addict,
and families and community are left in the background. For instance,
a good number of family members complain bitterly to treatment facilities
when they discover that their loved one was discharged for not making
his bed or not doing chores. Many programs do, however, provide
help to the family. These programs generally focus on concepts related
to ‘co-dependence’. Codependence implicitly states that
family members of addicts are also defective. In fact, a famous
video shown in treatment even claims that codependents have abnormal
brain chemistry! And 12-step programs for family and friends of
addicts, Al-Anon and Nar-Anon, also suggest that members complete
a step four and examine their own defects of character.
The evolution of the Minnesota Model has created
tension between those who see the model in terms of prohibition
and those who are more scientifically oriented. Patricia Owen (2000)
reported that Hazelden no longer discharges a client merely for
using during treatment and that the clinician works with the client
to develop individualized treatment plans. In fact, Hazelden now
sees a confrontational counseling style as harmful to certain segments
of the addict population, such as the elderly or abused. (And Hazelden,
itself, offers a graduate degree in addiction counseling.)
But the new thinking has not filtered through
to most programs, which continue to apply the old thinking with
its prohibitionist attitude. I have shown Hazelden’s newer
version to counselors in abstinence-based treatment facilities.
Most of the staff shake their heads and complain that Hazelden has
obviously watered down its program under pressure from misguided
governments and researchers.
Neurobiological reductionist view
The abstinence approach is also rooted in the
view of some physicians and neuroscientists, who reduce addiction
mainly to the effects of drugs on the brain. For these scientists,
the addict’s problem is that her brain has altered genetically,
structurally, and chemically to the drug. The addict’s brain
thus requires time to rebalance itself. True to their Hippocratic
Oath, many physicians certified in addiction medicine believe that
it is unethical, for instance, to prescribe a mood-altering drug
to patients whose very problem is mood-altering drugs. Those in
recovery who ask for methadone, sleeping pills, painkillers, or
anti-anxiety medications are not sincere about recovery and are
simply ‘drug seeking’. Typically, the physician discontinues
all medications for the recovering patient to allow the brain to
rebalance itself naturally. If symptoms such as depression continue
after, say, three months, then the physician knows that the depression
is not the result of drug use but is naturally occurring, and a
prescription of anti-depressants is warranted.
Similarly, some therapists refuse to provide
services to a recovering addict unless she has at least one or two
years of total abstinence. These therapists argue that because the
addict’s brain has adapted to the drug, therapy has little
value in the first one or two years.
Outcome measures define success by total abstinence.
Gorski and Marlatt (1996) suggested that as many as one-third of
treatment facilities had abstinence rates of up to 65 percent over
a year, but most studies pin the success rates somewhere around
25 percent or less for up to one year (Miller & Hoffmann, 1995).
After one year, the success rates drop significantly. The Rand Corporation
(Polich, Armor, & Braiker, 1980) published a rate of 7 percent
over four years, and Vaillant (1995) reported that only about 5
percent sustained long-term abstinence.
Abstinence and political policy
Abstinence reflects the American policy of seeing
addiction not only as a health issue but also a moral failing. Addiction
as a lack of morality is extraordinarily powerful in the United
States and impressively popular in Canada. Moral stances have, for
example, secured government control over drugs by attempting to
legislate them out of existence. Most of us are familiar with federal
attempts to ban alcohol after the First World War, and today both
Canada and the United States continue to criminalize drug use. The
defining legislation in America was the 1988 Federal Anti-Drug Abuse
Act. Its policy goal was the "creation of a drug free America,"
the so-called declaration of war on drugs (Marlatt, 1998), though
the informal declaration was pronounced in the 1970s. The Act also
created the Office of National Drug Control Policy, whose head is
known as the ‘drug czar’.
Focused on reducing drug use, the policy has
emphasized supply and demand reduction, rather than treatment and
prevention. In practice, this has, for instance, linked foreign
trade agreements with how closely the trading partner’s policies
on drug use match those of the United States. It has also meant
strengthening domestic enforcement. Marlatt (1998) cites studies
from the National Center on Addiction and Substance Abuse at Columbia
University that describe the intensity of this effort. Since 1980,
the number of inmates in the United States has tripled, “and
illegal drugs and alcohol had helped lead to the imprisonment of
four out of five inmates” (p. 359). Today, enforcement continues
to ride at the fore in the war to keep American drug free, with
70 percent of the federal drug budget targeted to enforcement (in
Canada, about 30 percent goes to enforcement).
Ethical concerns with abstinence
Abstinence has many questionable ethical practices.
Many programs follow a ‘three-strikes-and-you’re-out’
policy; thus, clients are often discharged for not making their
beds, showing up to group more than 30 seconds late, eating supper
with the same client twice in a row (known as pairing), not doing
their daily chore, and any number of infractions in the rulebook.
Counselors who have earned advanced degrees,
with their required course in ethics, have questioned the coercive
therapeutic techniques. It is difficult to justify the ethical validity
of coercion and shaming as a style of counseling, especially since
current standards emphasize a client-centered approach. Unfortunately,
one of the realities of a confrontational style is that clients
who are difficult to work with are routinely discharged under the
guise that they are not ready for treatment.
The rigid rulebook generally translates into
a ‘one-size-fits-all’ treatment. These programs do not,
for instance, appreciate multi-cultural issues. An East Indian man
in treatment may find it demeaning to do chores, yet a refusal guarantees
discharge. An ESL client may be confused about the rules and unintentionally
break them. One Sri Lankan client in Vancouver went to the dentist
to have a tooth extracted and was prescribed a narcotic for pain.
Under the dentist’s direction, he took one of the pills immediately.
Acting in good faith, he turned in the bottle of pills to staff
at a facility and was immediately discharged when the staff member
saw that one pill was missing. Similarly, the abstinence approach
has been condemned as a treatment for many women. A confrontational
style of counseling may be harmful to abused women. And we could
argue the same point for men who have been abused by authority figures
and by lovers.
Many treatment providers refuse to deal with
clients who have co-occurring disorders, such as schizophrenia or
bipolar disorders. Ken Minkoff (2005) has lobbied hard to convince
abstinence programs that refusing service to concurrent-disorders
clients because they take prescribed mood-altering drugs is unethical;
conversely, demanding that these clients stop taking medication
is tantamount to medical malpractice. Historically, these poor souls
have slipped through the cracks: denied services in mental health
because they were addicted to drugs, and denied services in addictions
treatment because they were prescribed antipsychotic and mood-stabilizing
Similarly, many abstinence programs refuse methadone
clients, even though the American Society of Addiction Medicine
(2001) has declared that Methadone Maintenance is an acceptable
form of treatment for opiate addiction.
Clinical concerns with abstinence
Despite their popularity, abstinence programs
have come increasingly under pressure from research. Scholarly studies
based on motivation theory, pharmacotherapy, and cognitive-behavioral
therapy have shown that abstinence is not the sole route to recovery
Although the abstinence approach has argued
that drug use is the defining feature between recovery and addiction,
most experts believe that recovery is more accurately represented
as a process in which clients move through a series of distinct
stages, including relapse (Prochaska, Norcross, & DiClemente,
The zero-tolerance approach has also encouraged
a remarkably high attrition rate in treatment. DiClemente, Bellino,
and Neavins (1999) reported meta-analyses of outcome studies that
found an average attrition rate of 70.6 percent, though the usual
is closer to 40 percent. A growing number of professionals in the
field are frustrated that abstinence makes unrealistic demands on
clients. Comparing addiction with schizophrenia, one addictions
physician told me that discharging an alcoholic for relapsing is
like discharging a schizophrenic for relapsing: it is not a reason
for discharge but a reason to work with the client.
Treatment outcome studies have shown that many
non-abstinence programs are successful. Studies that define success
by increased well-being in various life areas—rather than
abstaining from drugs—report that clients have led much healthier
lives despite not being completely free from drugs and alcohol.
Key points of abstinence treatment approach
- Addiction is a disease—Generally,
addiction is seen as a disease that has no cure but which can
be controlled through abstinence. (Note: 12-step programs agree
with this disease concept; however, ‘secular’ abstinence
programs do not interpret addiction as an epidemiological disorder.)
- Addicts have pathological personalities—Clients
are seen as suffering from defective personality traits and neurobiological
adaptation to the drug. (Note: Although 12-step programs highlight
‘defects of character’, secular mutual aid societies
interpret addicts a suffering from faulty cognitions.)
- Focus on addiction—Treatment is not
aimed at a whole, complex individual; rather, it limits itself
strictly to the ‘addict’ and the ‘addiction’.
- Therapists take control of clients—Because
clients are in ‘denial’, counselors are directive,
set behavioral standards, and determine who is ready for treatment.
- Behaviorism is preferred theoretical stance—Though
cognitive therapy is often used in abstinence programs, most demand
that clients act in a prescribed manner.
- Confrontation is the recommended counseling
style—Counselors must break through the addict’s ‘denial’
for recovery to proceed.
- Success is measured by abstinence from all
mood-altering substances—Even the use of prescribed mood-altering
drugs means relapse.
- Attendance at 12-step programs is essential—Minnesota
Model and TSF programs see AA, NA, and their siblings as the change-agent
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