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.
Abstinence-based programs—particularly 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 policy.
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 and sincerely.
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 medications.
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 from addiction.
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, 1995).
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 of recovery.
American Society of Addiction Medicine. (2001). Public policy of ASAM. Retreived March 28, 2003, from http://www.asam.org/ppol.
DiClemente, C., Bellino, L.E., & Neavins, T. (1999). Motivation for change and alcoholism treatment. Alcohol Research and Health 23(2), 86-92.
Forcehimes, A.A. (2004). De profundis: Spiritual transformations in Alcoholics Anonymous. Journal of Clinical Psychology 69(5), 503-518.
Frey, J. (2003). A million little pieces. New York: Random House.
Gorski, T., & Marlatt, G.A. (October, 1996). Alcoholism: Disease or addiction? Counselor: The Magazine for Addiction Professionals, 294.
Hart, K.E. (1999). A spiritual interpretation of the 12-steps of Alcoholics Anonymous: From resentment to forgiveness. Journal of Ministry in Addiction & Recovery 6(2), 26-28.
Lemanski, M. (2001). A history of addiction & recovery in the United States. Tucson, AZ: Sharp Press.
Marlatt, A.G. (1998). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: The Guilford Press.
Miller, N.S. (1995). History and review of contemporary addiction treatment. Alcoholism Treatment Quarterly 12(2), 1-22.
Miller, N., & Hoffmann, N.G. (1995). Addictions treatment outcomes. Alcoholism Treatment Quarterly 12(2), 41-55.
Minkoff, K. (2000). An integrated model for the management of co-occurring psychiatric and substance disorders in managed care systems. Disease Management & Health Outcomes, 8, 250-257.
Owen, P. (2000). Minnesota Model: Description of counseling approach. In J.J. Boren, L.S. Onken, & K.M. Carroll. (Eds.). Approaches to Drug Abuse Counseling (pp. 117-126). Bethesda, MD: National Institute of Drug Abuse.
Polich, J.M, Armor, D.J., & Braiker, H.B. (1980). The course of alcoholism: Four years after treatment. Santa Monica, CA: Rand Corporation.
Prochaska, J.O., Norcross, J., & DiClemente, C. (1995). Changing for good. New York: Avon.
Tiebout, H.M. (1944). Therapeutic mechanisms of Alcoholics Anonymous. American Journal of Psychiatry, 100, 468-473.
Vaillant, G.E. (1995). The natural history of alcoholism revisited. Cambridge, MA: Harvard University Press.