In the midst of winter here in Scotland when days are short, snow is on the ground and we’re in lockdown, it’s easy to get low. I’ve been thinking a lot recently about residential rehabilitation and where it fits into treatment options.

I think it’s true to say that rehab has felt a bit stuck in a kind of permafrost of neglect or obscurity. Rehab seems irrelevant to some and dangerous to others, yet those who have benefitted have often reported a transformative experience. Then there is the difficult fact that relatively little public funding supports the hundreds of people who go through rehab every year. The majority pay for their own treatment or are funded by insurance or charity. (For those not familiar with Scotland, almost all health interventions here are funded publicly). But there are glimmers of light, or, some might even say, beams of light, playing out now on our wintry shores and mountains.

It’s true that it’s only been a couple of months since our bleak drug-related deaths figures for 2019 were published, darkening the winter further, but this year the response has been different – after the outrage and sadness came listening and commitment to improve the situation – from the highest level in government. There have been brisk responses before admittedly – so what’s different this year?

As it turns out, quite a bit.

Changes afoot

In a significant move, Scotland’s first minister, Nicola Sturgeon, has appointed a new Minister for Drugs Policy who will lead on tackling our problems. In a speech yesterday, the Minister – Angela Constance MSP – pledged to ‘do more, do it better and do it faster’, in order to save lives.  

Ms. Constance said that she will continue to meet with those with lived experience, parents and other family members. She said she would build consensus both within and outwith the Parliament. I was happy to see that she will embrace both harm reduction and the promotion of routes to recovery, including residential rehabilitation. Polarisation has had its day. She rightly accepts that we need many solutions to our challenges.

The Minster also wants to ‘make sure that our own house is in order’. By this she means joining things up across different government departments – such as work on adverse childhood experiences (ACEs), mental health, homelessness, the justice system and tackling poverty and inequality. Over the years I’ve tried to do this on a much smaller scale locally, but multiple chains of command, clashing philosophies, competitive attitudes and differing priorities make joined-up work very difficult to operationalise.

Joined up for recovery

However, the vow to take this work forward is welcome news. Such coordinated approaches are essential for recovery-oriented systems of care (ROSCs) to work effectively. Remember, we’ve been trying to get ROSCs up and running for many years – the Essential Care report called for this as long ago as 2008. The development of ROSCs was a focus of the last, and the current, drug (and alcohol) policies. ROSCs were called for in the Independent Expert Review on Opioid Replacement Therapy in 2013. That report was stark:

The review found considerable variation in local delivery of even the core elements of recovery orientated systems of care (ROSCs). Many areas stated their plans were at very early stages of development. There was little evidence presented by some ADPs regarding a real impetus towards recovery. Stakeholder reports supported this view.

Independent Expert Review, 2013

Things may have come on a bit, but how much has really changed in the last 8 years? Our challenges have become all-too-familiar bedfellows.

The power of rehab

In her speech, Ms Constance acknowledged the urgent necessity to reduce harms now and cited ‘the power of residential rehabilitation’. I hope that’s a phrase we hear again and again. As a treatment option which is difficult (and in some areas impossible) to access, unless you are wealthy, this was gratifying to hear.

We need every treatment dish on the menu so that people can get the help that’s best for them and their families when they need it. Whether that’s access to safe injecting spaces, equipment for safer injecting, drug testing services or entry into medication assisted treatment programmes or residential rehab, all need clear access and easy-to-navigate links between services which, too often, seem to sit in silos.

We’ve actually started working on issues relating to rehab in Scotland already. The Residential Rehabilitation Working Group was set up last year by Joe Fitzpatrick, the then Public Health Minister. We published recommendations last month. You can read more about what we found here.

Commitment

Meantime, we have a profoundly exciting promise which does suggest the heralding of spring for residential rehab in Scotland. Ms. Constance said:

The First Minister will make a statement next week laying out how we will achieve a step change in the short, medium and longer term. That will include a commitment to increase the provision of residential rehabilitation and bring our bed numbers up to the European average.

Angela Constance MSP, January 2021

The way forward

Our group estimated that fewer than 5% of all treatment episodes in Scotland in 2019-20 were for residential treatment, compared to an average of 11% in Europe. This means we are setting an ambitious target. I’m a big fan of setting the bar high, but this means committing to a lot of hard work to sort out barriers to treatment. These include challenges around capacity, access and pathways, understanding the various models of treatment, setting standards, adequate duration of treatment, and of course, having sufficient and straightforward funding.

Then there is the difficult and somewhat perplexing issue of understanding and tackling the ambivalence, iciness, or even hostility that some professionals have towards rehab. This can result in a glacial rate of referrals from certain areas or teams.

The right to be involved in choosing what kind of treatment is right for you is set down in our drugs strategy, Rights, Respect and Recovery and this should apply as much to residential treatment as it does to other valid choices. Where attitudinal barriers exist, they need to be identified, discussions and education had, and channels opened up.

Finally, we need to address the dearth of evidence on outcomes from rehab. We only have one rehab study from Scotland  published in a peer-reviewed journal. That’s despite over a thousand people going through rehab in Scotland every year and rehabs being around for three decades or more. Who are these rehab graduates? What took them to rehab? Did they have prior episodes of treatment? What happens to them afterwards? What value does their recovery have to them, their families, their country and the recovery community? Does rehab have an effect on reducing alcohol and drug deaths?

Aren’t these interesting questions? Why the frigidity?

Can it ever be valid for someone to say ‘there’s no evidence that rehab works’ when the issue is nobody is interested in gathering and looking at the evidence? I don’t think anyone is claiming rehab is the answer to Scotland’s drug and alcohol harms and deaths. It should, however, be another valid option on the menu of treatment choices and currently in many places, it is not.

Hope

Once we’ve identified them, barriers and challenges can be overcome. With the right will, leadership and resources, there are things we can do quickly and there are things that need a bit more groundwork and planning, but which will thaw us out of winter and into spring. 

There’s a warmth in the wind. It’s feeling good.

Follow me on Twitter @DocDavidM

Negative Space and Art

In visual art, the area outside or around the main object is called “negative space”.

For example, if one draws a deer and places the deer on an abstract background, the abstract background is termed “negative space”.

In art, negative space is important.

What should the negative space be made of? And how should the negative space be made? How should the negative space be made to seem?

Sometimes, making the right choices in the design and use of negative space makes all the difference in how the actual “subject” of the art is perceived.

The main object may be interpreted one way with one contextual frame or appear very differently with another. In that way, the negative space may be more critical than the way the artist renders the main object or main subject of the work itself.

These are important considerations. After all, different people may have different subjective interpretations of the negative space. And thus, people will have different interpretations of the object itself, if only due to their differences in their way of experiencing the very same negative space.

Negative Space and Human Interaction

Relating and interacting with another person generally has an object or a topic.

That subject or topic sits in 1) the negative space we create, 2) the negative space the other person creates, and 3) the negative space that the two people co-create together.

Think of the zone of interaction between two people as a certain kind of negative space – the kind created by those three sources.

But stop to consider that negative spaces are also evaluated. And as in art, the perception and evaluation of the negative space changes the evaluation of the main topic, object, or focal point of the interaction.

Endeavoring toward a more intentional rendering of our context, rather than our content, might be helpful in our interactions. Can we make the aesthetic evaluation of the negative space (in our daily interactions, and the counseling we provide), part of our recipe or menu of considerations in creating, forming, and holding negative space?

Negative Space and Addiction Counseling

In the science and art of addiction counseling, what is the negative space?

Is it the room? Is it the silence? Is it the unthought-known below our conscious mental operation? Or some combination of these?

In the practice and art of addiction counseling, what negative space do we create? What look and feel do we give the negative space that we bring about?

What about the person undergoing addiction counseling? How do we apprehend and interpret the negative space that person provides? And how do they interpret ours? Are we each holding the best possible negative space for the sake of the process?

Negative Space, Addiction Illness, Addiction Recovery

Likewise, the one we assist and support, both forms and holds negative space during their illness, during their treatment or care, and during their recovery.

Someone experiencing addiction illness could form negative space during, and merely by, periods of abstinence – not just of use.

While they partake of addiction counseling how does the person served form, have, and hold negative space?

Negative Space as Cause and Effect

It is axiomatic that “Creativity is close to spirituality.” In that sense, what kind of negative space do we create, co-create, and hold?  What quality of negative space do we first render and then bring to others?  Is the negative space in the lives of those we touch improved by the impartation from the negative space we bring?  In what ways, and to what degree?    

What would an art therapist say about the outcomes found in the aesthetic dimension of the negative space in the lives of those we serve?

This podcast involves three of my favorite people. It’s a conversation about recovery in the context of community. It’s brief and well worth your time. Enjoy!

Which teachers were the best when you were at school? Likely the ones who believed in you, connected with you, who had a vision for where you could go and who enthusiastically helped you get there. I remember struggling with maths at school – I was always a writer, not an adder. Unfortunately I needed a higher level maths qualification to get to medical school.

Good teachers got me there. The same characteristics – vision, enthusiasm, affirmation, belief patience, engagement and holding out hope when there may not be much around, are likely to define the best clinicians too.

Limitations of treatment

In 2014, Pillay, Best and Lubman took a look at Australian clinicians’ attitudes to recovery in a research paper. They started by looking at the limitations of treatment

Now I have to say those themes are just as relevant today as they were six years ago. Perhaps more so.

What is ‘recovery’?

Plenty of definitions exist, but lack of agreement on what recovery actually is can be a problem. The role of abstinence is seen as contentious by some. As recovery is often seen as a process, say the authors, it is difficult to measure and may be better captured by a set of principles.

The study background

The authors explain the context to the study: research supports the idea that clinician attitudes can influence client outcomes, where clinicians who are more positive about being able to support client recovery achieve better client recovery outcomes. Conversely, ambivalent or negative clinician attitudes are associated with increased client relapse and reentry into treatment.

I remember a manager of a service saying to me a few years ago, when those with substance use disorders still had to turn up at the Benefits Agency to claim benefits, that if his clients could out out of bed and get there, that was recovery as far as he was concerned. I remember thinking ‘that’s surely a low bar’.

Clinician attitudes

The aims of this paper are fourfold:

  1. What do clinicians think ‘recovery’ means?
  2. What do they think are the risks and benefits of moving to a recovery-oriented approach?
  3. Do service types and other variables influence attitudes?
  4. Finally, what are clinicians’ expectations that their clients will eventually achieve recovery?

The study

Fifty alcohol and other drug clinicians from a variety of backgrounds completed questionnaires. Thirty-five of them also took part in structured interviews.

Definition of recovery

Just over a third said that recovery was ‘moderate controlled use of any drug and alcohol’. A further third said ‘no use of any drug or alcohol’ with the rest in between or not answering.

Risks and benefits of a recovery approach

There was much agreement of the potential benefits, with residential treatment providers being most positive. On the other hand, some said, ‘that’s what we are doing already’ (always sends up a red flag for me) and expressed concerns that if clients didn’t have recovery goals, then recovery services may seem to exclude them. The balance of harm reduction services and recovery services was also highlighted and the place of 12-step groups ‘imposing recovery’ was mentioned – whatever that means. Could it be the ‘high bar/low bar’ issue again?

Expectation of recovery

Just over half made a stab at estimating the proportion of clients they thought would eventually achieve lasting recovery. The clinicians reckoned about a third of their clients would get there. The world literature suggests it’s about half. In studies professionals consistently underestimate what their clients want and are capable of.

Study Conclusion 

The authors conclude that the term recovery is a contentious one, with many different interpretations and associated attitudes. They suggest that as services embrace change, it will be worth taking time to work with clinicians to create an atmosphere which is conducive to a Recovery Oriented System of Care. To help the process, rather than trying to pin down ‘recovery’ precisely, an ‘overarching set of principles’ will be more useful. Getting recovering people involved in the discussion will be an important catalyst.

Reflections

It’s interesting to me (but not surprising) that residential treatment providers were the most positive about a recovery approach. We get to see lives transformed through the process of recovery and, in aftercare and beyond, see recovery being sustained. That’s not always something colleagues in different parts of services see.

Getting recovery-oriented systems of care established and working well has been highlighted as important in the last drugs policy and in this one. Everything joined up from harm reduction services (drug consumption rooms for instance) to residential rehab and community recovery resources. Would be good to see these operational across Scotland.

This theme of the importance of lived experience detailed in this study (embedded in the Scottish Government’s drug policy Rights, Respect, Recovery) is welcome. The recently-appointed drugs minister, Angela Constance MSP, has just tweeted a commitment to that very thing which can only be welcomed.

Irene Pillay, David Best & Dan I. Lubman (2014) Exploring Clinician Attitudes to Addiction Recovery in Victoria, Australia, Alcoholism Treatment Quarterly, 32:4, 375-392, DOI: 10.1080/07347324.2014.949126

This is an updated version of a previously published blog.

Our substance use care infrastructure and workforce has never been in particularly good shape. It is largely held together by passionate people who care about the work and who serve in the face of a myriad of barriers and challenges. It is a constant upstream swim even in the best of times. This is a result of systemic negative perceptions about substance use disorders, the people who have it and the workforce that serves them.

I have become increasingly concerned in recent years about the lack of longevity in our workforce and high rates attrition and the impact of these dynamics on the quality of care provided. These trends have both increased, and from my perspective largely are a result of high administrative burden, low compensation and an aging workforce, all exacerbated by the underling stigma against the disorder and everything related to the work. As a result, there are few us who stick and stay long enough to develop some level of mastery and insight into how our care systems integrate and relate to the rest of healthcare. We are losing institutional knowledge and it is not being replaced. Even before COVID-19, this SAMHSA Behavioral Health report indicated we will need around a million and a half counselors and a million peer support professionals. This is a huge problem.

And now we have the confluence of contagions – the addiction epidemic as it unfolds in the midst of the COVID-19 pandemic. News reports highlight the grim reality that our healthcare systems are being pushed beyond the brink. COVID patients are being treated in hospital gift shops or triaged and left to die at home if they are viewed as unlikely to survive with medical intervention. If this is occurring across the US medical healthcare system – the best funded in the world as we spend many multitudes of what other nations do on healthcare. What will our ragtag SUD care system face with the coming waves of addiction in coming years? 

There are hints. This New York Times article “Relapsing Left and Right: Trying to Overcome Addiction in a Pandemic” indicates we have already lost up to 10% of our treatment capacity and nearly half of the facilities are operating at around half capacity. We need to understand the context under which the influence of the COVID-19 pandemic will have on addiction rates here in America. We know people are using more substances to sooth anxiety, even as a large segment of our population is being exposed to significant trauma, both which will tend to increase addiction rates. This is a dynamic that will play out at increased rates over the next decade.

So I am left with more questions than answers. Without serious investment and redesign oriented towards long term wellness, we will simply not be able to handle what is coming at us. We need to strengthen our foundations and build out a functional care system in consideration of long-term needs. It would be hard to argue we have made much progress towards that end as our care system is already withering under the initial pressures of what will be a decade long impact at best.

A full redesign of a care system oriented towards recovery could only come from serious investment in resources. We can do things now which would help set up an environment to support a more robust system. We could get rid of the IMD Exclusion, set aside dedicated funding for authentic recovery community organizations and require insurance companies on the private side to fund more than acute care models. I put together set of things to consider related to a longer term care model here. 

Typically, when such policy reports are developed, a small group of well-meaning people is pulled together and they churn out a white paper. It gets published and becomes a dust collector. We need to think and act bigger to save lives and resources. We should start with a broad discussion of system redesign modeled on the mentality that recovery is the probable outcome across all our communities and then design and implement care that achieves this goal inclusive of the diverse communities impacted by addiction. A model that contains harm reduction measures, acute treatment, long term recovery support and is consistent with the diverse needs of all our communities. While this is the vision – the answers are going to involve all of us. What will drive it if anything is the imperative to address what is coming at us.

The clock is ticking and what we do now will impact what happens as the devastation plays out over the coming decade.

Drink does not drown care, but waters it, and makes it grow faster

Benjamin Franklin

When we consider the things that make us vulnerable to addiction – trauma, poverty, lack of opportunity, stress, stigma, genetics and environment, it’s no surprise that relapse and the development of problems with other substances occur after treatment. These problems don’t resolve quickly, if at all.

The attempt to soothe cares, pain and distress with alcohol, the permitted drug, is understandable. I hear stories every week from my patients about their experiences of putting down one substance and picking up alcohol (or other drugs) only to find their problems worsening.

Last year, I took a look at the issue of risks of developing an alcohol problem for those in recovery from other substance use disorders. It seemed as if they were significant.

In their recently published study, Greg Rhee and Robert Rosenheck have helped to quantify this risk this a bit more. They sought to estimate how common alcohol use disorder (AUD) was in those who had recovered from other substance dependence.

Context

As the authors say, individuals who use one substance ‘are recognised to be at greater risk of using other, often multiple, substances’. Previous research suggested that ‘alcohol use, especially heavy drinking, may be overlooked and underestimated among patients recovering from substance misuse’. Alcohol consumption has also been linked to increased risk of relapse back to the drug of choice, but it has been difficult to quantify risks.

What they did

The researchers took a look at data from just over 2000 adults who had previously suffered from substance use disorders (e.g. opiates, cocaine and other stimulants) but who were now in recovery. They divided this group into three – those who had no history (past or present) of alcohol use disorder (AUD), those who had a past, but not current, history of AUD and those who currently met the criteria for AUD. Then they looked at relevant factors for all three categories, such as other diagnoses, demographics and quality of life indicators.

Interestingly, the largest group in the sample was those with cannabis use disorder (60%), followed by cocaine use disorder (31%) and stimulant use disorder (21%) with only 17% having an opioid use disorder.

Findings

More than three quarters had either a current (29%) or a past, but recovered (48%), AUD. Less than a quarter (23%) had no history of AUD. Those who had a current medical or mental health problem were more likely to have a current AUD. They were also less likely to be married and more likely to be a bit younger.

What does it mean?

It means that a significant proportion of the people recovering from non-alcohol substance use disorder seem to be at risk of AUD. 

Alcohol use disorder is the most common co‐occurring lifetime substance disorder among those recovered from substance use disorder

Rhee and Rosenheck 2020

Although the distribution of the problem substances in this population would certainly seem not to be typical of a Scottish treatment population, limiting generalisability (there are other limitations listed in the paper), there are lessons here. 

Statutory treatment provision here has been criticised as focussing on opioid treatment in a service-user group who are often suffering from problem poly-substance use. This is a broad generalisation, but could we do better, given the evidence on poly-substance use risk seen in our drug-related deaths data? In particular, based on this study, it looks like we need to look at alcohol risks. Service users need and deserve to have information about this.

What would help is to have clear policies, practice and education to try to reduce risk, to screen for AUDs, to treat co-occurring AUDs and to allow service users to hear peer experiences on the issue. Some of this is happening already – in my place of work, this comes up again and again and is a topic in our educational programme. 

This study helps us begin to put some flesh on the bones of the issue and ought to inform policy and practice.

Rhee TG, Rosenheck RA. Alcohol Use Disorder Among Adults Recovered From Substance Use Disorders. Am J Addict. 2020 Jul;29(4):331-339. doi: 10.1111/ajad.13026.

Photo credit istockphoto.com/ilze79 – under licence

We’ve finally made it to 2021—a new year, a clean slate, a great time to start over. Whether this is your first time or fifth time going through the 12 Steps of Alcoholics Anonymous or Narcotics Anonymous, the very first step remains just as important every single time. The first step is the beginning of an exciting journey to healing and recovery.

We admitted we were powerless over drugs and alcohol—that our lives had become unmanageable.

Substance use disorder (SUD) is cunning and baffling. It speaks to you in your own voice and can lead you to believe that you can manage the complications caused by substances on your own. The truth is, you can’t out-think the disease. It fills you with shame, guilt, and other negative feelings that cloud your judgment about yourself and the world around you.

Attending a treatment facility or beginning to attend AA or NA meetings can be the start of the first step for someone suffering from SUD. Other times, individuals may begin doing those things to appease others such as their family members and friends, instead of truly seeking a genuine path to recovery. For recovery to “stick”, you must come to a full surrender. You must be honest with yourself, open with others, and willing to do the work that it takes as your time in recovery goes on.

In the circumstance of recovery, surrender is an incredibly powerful thing. In this vulnerable moment of truth with yourself when you accept that you cannot manage your disease alone, you open yourself up to begin your new life.

Though the word may play on some of your insecurities, powerlessness over drugs and alcohol doesn’t make you weak. Recognizing powerlessness actually empowers you to make a change in your life. The courage that it takes to admit this requires immense strength. In this humble moment of asking for help, you have given yourself the opportunity that is sobriety and recovery. Acceptance that you have a problem, and that you need the guidance and wisdom of a higher power and others to heal is the true beginning of the first step.

Step 1 doesn’t require you to immediately fix everything in your life that you’ve broken, it doesn’t ask you to do a massive overhaul and change everything right away or “get better” overnight. It simply asks you to accept that you have a problem, admit that you can’t fix it on your own and that you need help. It also is important that you seek these truths for yourself and no one else. The beautiful thing about the 12 Steps is that they are designed to lead you to a slow and steady understanding of recovery and rebuilding your life at your own pace.

You should talk to your sponsor or a close contact in your recovery network about working the steps. It is important to seek the wisdom of someone who can provide you with guidance and a full understanding of the situation–another person in the program (AA or NA) with afflictions similar to yours who is compassionate and can help you understand the meaning and importance of each step.

***

For more information, resources, and encouragement, “like” the Fellowship Hall Facebook page and follow us on Instagram at @FellowshipHallNC.

About Fellowship Hall

Fellowship Hall is a 99-bed, private, not-for-profit alcohol and drug treatment center located on 120 tranquil acres in Greensboro, N.C. We provide treatment and evidence-based programs built upon the Twelve-Step model of recovery. We have been accredited by The Joint Commission since 1974 as a specialty hospital and are a member of the National Association of Addiction Treatment Providers. We are committed to providing exceptional, compassionate care to every individual we serve.

Dr. Reid Hester

Dr. Reid Hester is a psychologist and researcher.  He is the founder and director of the science division of CheckUp & Choices.  Reid’s extensive research in alcohol abuse has led to professional opportunities and collaborations with many experts in the field.  One long-standing partnership has been with SMART Recovery. 

In this podcast, Reid talks about:

Additional resources:

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Recently, I have seen yet another wave of anti-12 step promotion via various digital formats and blogs. The various talking point involve, “AA is not evidence-based”,”AA has incredibly low success rates,” and a variety of cultural criticisms and safety warnings. Time and time again I run across people who quite suddenly demand that I offer evidence of AA, when I speak affirmatively about it. As such, I have decided to assemble, once again, a solid collection of openly accessible articles that I generally consider the evidence base for 12-Step efficacy.

I usually take the time to qualify the challenges of researching a self-selecting group, with anonymous members, and the ethics that prevent RCT study generally. I also try to outline some of the statistical maneuvering that is used to get around this. For the AA skeptic, the minute you begin to explain these things, there is a, “Tsk, tsk! Sounds like you are trying to make excuses!” So, for the purposes here, I will simply let the authors of the various articles speak for themselves. All of these article are openly accessible and do not exist behind paywalls.

I am also not going to break down these articles and explain them one by one. This is intentional and for a very simple reason- All too often, someone will demand evidence of AA efficacy, who then don’t bother to read the article offered in any serious way. Why? The answer is because they are not truly interested in the evidence for AA. They are interested in confirming their own biases to prove or disprove the 12-Steps. By not breaking down these articles, I am filtering out those types unwilling or uninterested in learning about 12-Step research. Additionally, we are all adults and we can all do our own homework.

Let’s Begin

Keith Humphreys, Ph.D., Janet C. Blodgett, M.Sc., and Todd H. Wagner, Ph.D.

Kelly JF1, Bergman BG1, Fallah-Sohy N1.

Jane Witbrodt, M.P.H,*,1,4Jennifer Mertens, Ph.D.,2Lee Ann Kaskutas, Dr.P.H.,1Jason Bond, Ph.D.,1Felicia Chi, M.P.H.,2 and Constance Weisner, Dr.P.H., M.S.W.2,3

Lee Ann Kaskutas, Dr.P.H.

John F. Kelly, PhD

John F. Kelly, Robert L. Stout, Molly Magill, J. Scott Tonigan, and Maria E. Pagano

John F. Kelly, Ph.D., Robert L. Stout, Ph.D., Molly Magill, Ph.D., J. Scott Tonigan, Ph.D., and Maria E. Pagano, Ph.D.

John F Kelly,Keith Humphreys, and Marica Ferri

John F. Kelly,*M. Claire Greene, and Brandon G. Bergman

Yu Ye1 and Lee Ann Kaskutas1,2

Stephen Magura,a,**Joseph McKean,bScott Kosten,b and J. Scott Toniganc

J. Scott Tonigan, Elizabeth A. McCallion, Tessa Frohe, and Matthew R. Pearson

My Thoughts

Undoubtedly someone, somewhere, will parade this post out and decry it’s contents. I just want to ensure that if this is the manner in which you came across this post, then do yourself a favor and read the above articles.

Additionally, others will say there are other or better articles out there: There are literally thousands of peer-reviewed research articles on AA. I chose these articles because I often refer back to them in my own work, and because they are accessible to the general public. I encourage folks to respond in the comment section and link additional articles they may feel warrant additional consideration. Please make these articles available to the public, if paywalled, by using a Google Docs Folder and providing a link to it.

You’ll notice many of these articles go back quite a few years. This is a source of frustration to me: open, publicly accessible research on AA has been available for over a decade now. Anyone can find research on AA, and yet, even among professionals, researchers, and clinicians, I still hear the blanket statement “AA is not evidence-based.” These statements are usually accompanied by the assertion that anyone who defends AA (even from a research perspective), is somehow supporting “folk wisdom,” and is merely being “reactionary” and “cult-like.” My personal recovery experience does involve AA, which worked well for me. But this isn’t why I defend AA. Scientifically, I defend AA because there is good evidence to do so. Period.

The Questions Everyone Wants to Know

1.
Q: Is AA for everyone?
A: Absolutely not. Everyone should explore if it is right for them. Fortunately there is an AA meeting going on nearby, right now. It is free, and requires no commitment to check it out. We should encourage everyone to find out if it is right for them.

2.
Q: Should treatment be more than AA.
A: Yes and No. 12-Step groups are the only guaranteed resource post treatment. Virtually every client will be able to access a 12-step group, no matter where they go. They should be oriented to the program during treatment. Additionally, TSF is, in fact, an evidence-based modality. And finally, ALL treatment of any positive repute should do MORE than simply teach the steps. If they don’t, then I would question their model (and the cost, since you can literally get the same thing for free.)

3.
Q: What about “the God thing.”
A: See number 1

4.
Q: What about NA and their beef with MAT?
A: If you are on medication, I would suggest you try out several other meetings, like CA, and OAA which has no such qualms. Also, there are *some* 12-Step meetings specifically catered to those on pharmacotherapy. Look around, offer these to your clients if you’re a clinician.

5.
Q: What about rape culture, patriarchy, and WASP criticisms?
A: Re: Rape Culture- There have been incidences. This does not mean that the rooms are any more dangerous than anywhere else. These incidences have also been greatly magnified by the internet, and by the anti-12 Step proponents. Though people in the rooms ALL have checkered pasts. Part of the value of the rooms is the fact they accept everyone as is and makes no judgement about an individual’s past. The more dangerous element is 13th stepping which happens to BOTH men and women. This is why it is suggested not to date for a while, and you should probably not date people from the rooms. Part of the problem here is that early relationships in recovery excite the brain along the same reward pathways as substances. Clients should be educated about this and sponsors should discourage dating, not because the literature says so, but because it is part of being responsible to the community. If one is still uncomfortable, take a friend to an open meeting to get the feel of the group.

Meetings vary greatly by regions, towns, even parts of the country and across the various groups (NA, AA, CA) etc. One will have to deliberately try out several meetings in order to make an informed decision about whether or not 12-step groups are for them.

Re: Patriarchy- 12-steps, particularly AA, use the Big Book. It is a historical document, the language and format are heavily gendered. You will have to decide for yourself if this is a barrier to attending. Other groups may use more modern literature.

Re: WASP- Some groups are heavily populated by white people. However, this varies a lot. There is no definitive way to determine whether one will feel comfortable until they try out a few different meeting places and groups. It is not so much an ethnocentric group, as it is a class-centric group generally geared toward working and middle-class people. The highly educated may struggle, those with cognitive challenges may struggle, and (surprisingly) those who are highly religious may struggle. Still, none of these are bars to engagement.

Changes I Would Personally Make to 12-Step Groups

Before someone says “Yeah, but, what about…” I will say this:

NO: People should not be mandated to 12-Step groups. It isn’t good for the dynamics of a self-selecting community to have people forced into these groups. I would change this. Asking for attendance cards to sign at the BEGINNING of the meeting, and letting the people who do not want to be there go on their way is probably the best way to handle this.

NO: I don’t agree with NA’s ban on the participation level of people on medication. I believe it violates the traditions. NA does NOT speak for the whole of 12-step members. Particularly other fellowships like AA and CA. The great thing about 12-Step groups is that you can find other groups if you do not like a particular one.

YES: The 12-Steps are hard, and they may look intimidating for a variety of reasons. However, each step builds on the last one. And you do not work them alone, or without support from the group. Trust this process.

YES: If you have significant trauma, co-occurrence, or a history of abuse, you should also be engaged in therapy. The steps are rigorous, and they stir up a lot of uncomfortability. You should know this ahead of time. The steps ARE NOT therapy. They are designed to help you overcome a SEVERE issue with substances.

In Closing
12-step communities offer tremendous benefit to individuals and to local communities. The benefits far outweigh any negatives. You will need an open mind, and multiple exposures to groups and such exposure should be encouraged by clinicians. Taking someone’s word for it, or not going because of something you read on the internet is probably not going to provide you with enough experience. You will have to see for yourself. But, the evidence that it will help, is quite good, and the likelihood you will make life-long friends is high. Do not let prejudice stand in the way of finding out for yourself what it is all about. Although, to some degree, 12-step groups are a reflection of their collective members, individual members are not always healthy people. It helps to keep this in mind. The person in the front row who says something offensive may be on day 1 of their journey. It may not reflect the group as a whole, and definitely not indicate the value of 12-Steps as a whole. “Principles before personalities” is the key. Tolerance is needed and should be cultivated by anyone who attends on a regular basis. It is one of the values of recovery.

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I am a huge advocate for the five-year care paradigm. I have written about it extensively, including a STAT news article early this year and a piece with Dr Robert Dupont among others.  Put simply, the five-year recovery paradigm is a call to reorganize our care system around the fact that people who reach five years of recovery have an 85% chance of staying in recovery for the rest of their lives. Addiction was a leading cause of death even before the COVID-19 pandemic, destroying communities and costing vast sums of money. Expanding the number of Americans in long term recovery would be a game changer in America. We must focus on long term recovery for everyone with a severe SUD.

The frequent criticism I hear back is that we cannot afford to help everybody.  

Why do we ask this question about how we treat persons with substance use conditions? This is not a criticism we hear about other chronic medical conditions. We are not triaging persons with heart disease, diabetes or cancer and deciding which ones get full care and who gets palliative care. We need to ask some hard questions about how services are being deployed and for whom we stop care for at less harm rather than focusing efforts at getting everyone into treatment and recovery. A look at access to care for marginalized communities might give us a hint at that.  

Where does the mentality of triages and rationed services lead? In the US, what history shows us is that it has leads to care durations well below the minimum effective dose in lower intensities than necessary. We intervene at later stages in the condition to help people than we do with other chronic conditions where we have adopted an early intervention mindset. We typically wait until adulthood to address SUDs, often delaying help until after the person has had significant legal or medical problems that stem from the condition. Adolescent care for moderate to low-income families is hard to get. Here in Pennsylvania, we have lost most of our programming for young people, it may be true in other states as well. Addiction typically takes hold in our young people, yet we delay interventions for years and allow the condition to worsen – and then, after incarcerating people we say don’t have the money to help them, at least those in the bottom tier of the socioeconomic system.   

Who are the worthy drug addicts and who are the unworthy drug addicts?  How does bias against persons with substance use conditions, so prevalent among health professionals influence outcomes?

What happens when we decide a person, or a marginalized group has too far to go to get recovery and we do not think  that they can make it?  What history shows us is that we provide less care and less opportunity to obtain and sustain recovery and greater barriers to obtain help. Such determinations very likely have a whole lot more to do with the biases within our care institutions than the potential of persons with substance use conditions to get better.

Serious questions need to be asked about how the Pygmalion Effect plays out in who gets care and where the resources go. One of the things we see is that recovery community organizations – programs run by and for people in recovery scramble for scraps while groups perceived as more worthy like academic or law enforcement associated groups get the lion share of the limited resources. These are structural biases that emanate from stigma against persons with SUDs.

We should be looking at a addiction from an entirely different lens and considering what we have to gain by focusing on trauma resiliency. One area we need to look at more deeply building out a care system that fosters the “better than well” and community recovery as a public health intervention. Instead of focusing on an acute service infrastructure. We should consider the three key component parts of a theoretical model of recovery as articulated by UK researcher David Best and they include:

Recovery capital – personal and social resources – the journey of growth
Social identity and social contagion in recovery – the role of friends and connections
Therapeutic landscapes of recovery – the role of location

We can and should have a national conversation on the economics of recovery and addiction, there is not doubt that we would find that not only is addiction our most profound public health problem, but it is also our greatest opportunity to save lives, restore communities and save vast sums of money. This conversation must start with the premise that everyone is worthy of help and that we cannot afford to do anything other than to develop a system of care focused on recovery with equitable access for everyone. 

Everyone is worthy, and we cannot afford to do anything less than focusing a system oriented to long term recovery for everyone who experiences an addiction.

Let’s start with that basic premise.

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