Behavioral Treatments For Opioid Use Disorder

The ‘Community Connection’ paradigm is founded on the premise that addiction is a behavioral choice –often a logical, rational, and reasonable adaptation to external situations or events perceived to be outside of the control of the user –or a coping mechanism for internal thoughts and feelings that the user has not found a better or more effective way to deal with. For instance, a person may be more vulnerable to addiction when they feel dissatisfied with life, disconnected from other people, lack self-confidence, experience perpetual conflict, have recurring memories of unresolved trauma, or have lost hope. Periods such as adolescence, military service, and times of isolation or grief may cause people to become especially susceptible to dangerous drug and alcohol use. (Foote et al, 2014; Peele, 1992, 2016; Szalavitz, 2016) Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, and a ‘recovered’ individual herself, defines substance use as, “a normal response to an extreme condition” (Szalavitz, 2016).

The addictive substance provides rewarding and gratifying feelings that the individual is unable to get in other ways. It may block pain, uncertainty, or discomfort, or enable them to forget insurmountable problems, or may relieve stress or anxiety. It may provide artificial or temporary feelings of security or calm, of self-worth or accomplishment, of power or control, of intimacy or belonging. These benefits offer a rational explanation for why an individual keeps coming back to the addictive experience. The experience they have while using the substance offers something beneficial for them. (Foote et al, 2014; Peele, 1992, 2016)

Gradually, the addiction causes people to be less aware of and less able to respond to other people, events, and activities. Thus, the addictive experience reinforces and exacerbates the problems the person wanted so badly to escape in the first place.

With the worst addictions, jobs and relationships fall away; health deteriorates; debts increase; opportunities disappear; the business of life is neglected. The person is increasingly “out of touch” with nourishing contacts and essential responsibilities. This growing disengagement from the realities of life sets the person up for the trauma of withdrawal. When the addictive experience is removed, the person is deprived of what has become his or her primary source of comfort and reassurance. Simultaneously, the person “crash-lands” back onto an inhospitable world, a world from which the person has been using the addiction to escape. Compared with these existential torments, the purely physical dislocations of withdrawal are, even for most heroin addicts, not particularly debilitating. After all, nearly everyone who receives powerful narcotics in the hospital gives them up after returning home or when the illness is over. (Peele, 2016)

In essence, as the individual’s life becomes more unmanageable, they seek the comfort and reassurance of the substance, and thus, the cycle becomes self-perpetuating –causing a downward spiral that becomes increasingly difficult to escape. According to this explanation, drug use, like any other choice, is influenced by the individual’s preferences and goals. Despite subsequent dependence and harmful consequences over the long term, drug use is often viewed by the user as the best and most feasible option in the moment. (Foote et al, 2014; Heyman, 2010; Kurti and Dallery, 2012; Peele, 2016; Schaler, 2002; Szalavitz, 2016)

For enlisted troops in Vietnam, drug use became a very effective tool for coping with their environment. When they returned home, they no longer needed that particular coping mechanism, and so weaned themselves off of opiates on their own (See Spontaneous Remission, p. 66).

Situations in which people are deprived of family and the usual community supports; where they are denied rewarding or constructive activities; where they are afraid, uncomfortable, and under stress; and where they are out of control of their lives, are situations especially likely to create addiction. (Peele, 2016)

When people who use substances have alternative ‘reinforcers’ that they value more –marriage, job, college degree, active social life, housing, etc., they are able to voluntarily choose to reduce or end their drug use in order to attain that which they value more. (Bickel & Marsch, 2001; Heyman, 2010; Kurti and Dallery, 2012; Murphy et al, 2007; Walters, 2009) Studies show that meaningful rewards (learning opportunities, personal comfort, and social success) are effective in deterring participants from drug use (Carroll, Anker and Perry, 2009). There is an inverse relation between the amount of drug-free ‘reinforcers’ in one’s environment and the frequency of drug use (Carroll, 1996; Griffiths et al, 1980; Van Etten et al, 1998). Consequently, when these alternative reinforcers are both available and sufficiently valuable to compete with the value of drugs, an individual is more likely to abstain from drug use. Similarly, when the costs associated with drug use become too great, consumption decreases (Murphy and MacKillop, 2006). The costs of the drug use choice become so big that the non-drug alternative becomes more attractive. Hence, circumstances drive the individual to delay the gratification of immediate drug use, in favor of delayed future gratification. (Foote et al, 2014; Heyman, 2010; Kurti and Dallery, 2012)

When applying this theory to formal treatment, it becomes more about providing something better to do with one’s life than using drugs. When treatment providers view substance-dependent people as being victims of an imbalanced brain chemistry that forces them to maintain dependence, the treatment process ignores the person’s life problems and the functions that the drug serves for them. Ignoring the underlying feelings leaves the patient unable to cope with the very things that led him or her to become addicted in the first place. The relationship between hopelessness, lack of opportunity, and persistent addiction is a template for lives in many areas. When the causality of substance use is associated with external or situational factors, then the solutions for addressing the problem become drastically different.

Addicted people can best be helped by restoring their place in a functioning community. Effective treatment is not so much focused on ending drug use, as it is about providing access to a wide range of ‘recovery services’ –housing, employment, education, medical services, child care, counseling, recreation, etc. It is about reconnecting folks to the wider community and instilling a sense of belonging, usefulness, and positive group identities. (Alexander, 2008; Hart, 2013; Heyman, 2010; Lewis, 2012; Noe, 2016)

Recovery is about the self-discovery that leads to finding satisfaction in life, genuine satisfaction, life-sustaining satisfaction. This discovery includes finding the reasons, and habits, and feelings that underlay the past addictions, so as to sidestep and replace them. (Amy Lee Coy, 2010)

Abstinence-Based Residential Treatment, sometimes referred to as therapeutic communities, is a 3.1 level of care for individuals who no longer require detoxification services and who are capable of self-care, but not ready to return to family or independent living. This level of care can be provided in either a state-regulated halfway house or a recovery residence.

As opposed to recovering individuals who choose an opiate-maintenance or another medication-assisted treatment path, these individuals seek to modify their drug-using through behavioral interventions, rather than pharmacological interventions. Residents learn strategies and coping skills for maintaining abstinence from all drugs in a safe, controlled and supportive environment thereby gradually breaking their dependence on substances over time. They are assisted in learning techniques for preventing relapse, applying recovery skills, and reintegrating into the community within a 24-hour therapeutic, structured and supportive milieu.

Symptoms associated with long-term withdrawal, such as cravings, anxiety, depression, and insomnia are neutralized through small group support, counseling, and holistic therapies –many of which are presented in this section on behavioral interventions –psycho-social therapy, mindfulness/meditation, hypnotherapy, 12-step support, Self-Management and Recovery Training (S.M.A.R.T.), or faith-based recovery. Thus, the emotional toll of post-acute withdrawal can be sufficiently limited and any lingering physical withdrawal symptoms can be adequately managed.

Long-term therapeutic communities have proven effective in reducing or eliminating substance use, particularly opioid dependence, as well as the associated maladaptive or antisocial behaviors that have evolved along with it. The extent of improvement is directly related to retention in treatment. Numerous studies show that the amount of time spent in ABRT is proportional to the rate of success in achieving long-term recovery. However, most ABRT admissions do not complete the planned length of treatment. A recent systematic review shows completion rates from 9% to 56%. All studies showed that substance use decreased during residential treatment, but relapse was frequent after leaving the program. Treatment completion was the most predictive factor of abstinence at follow-up. (Uchtenhagen, 2013)

Among treated individuals, recovery prognosis is related to treatment dose, with those in remission averaging a longer duration of treatment than those still addicted. The underdosing of addiction treatment may be viewed as analogous to sub-therapeutic doses of antibiotics that may produce temporary symptom suppression but not lasting recovery. (White, 2012)

 

BENEFITS

• ABRT allows patients to eliminate their dependence on addictive drugs in a highly structured and supportive environment
• About 67% of ABRT patients do not use other illicit drugs while in treatment (Cohen et al, 2005)
• Suicidal ideation, prevalent in opiate users, is reduced by 41% – 47% (Hubbard et al, 1997)
• Increases in full-time employment correlate with patients remaining in ABRT for 6 months (Hubbard et al, 1997; Vanderplasschen, 2013) and ABRT patients show a higher rate of employment than methadone patients (Uchtenhagen, 2013)
• ABRT patients’ cognitive brain functioning may eventually be restored to pre-addictive states (Davis et al, 2002; Mintzer et al, 2004)
• A Cochrane Review comparing pharmacological and non-pharmacological treatments (ABRT) showed that there is no statistically significant superior effect on either criminal activity or mortality for either (Mattick, 2009)

RISKS

• Short stays (30 days or less) have about a 5% success rate. Programs that discharge clients after 30 days give the patient the false impression that they are healed, when in fact, only longer stays (at least 3 to 6 months) correlate with higher successful outcomes than outpatient treatment (Hubbard et al, 2003; Tiet et al, 2007; Uchtenhagen, 2013; United Nations –New York, 2002; Vanderplasschen, 2013; White, 2012)
• ABRT patients who resume opiate use at the same dosage level as prior to treatment are at a high risk of overdose, since their tolerance is much lower.
• Drop-out rates in long-term programs are significant (Vanderplasschen, 2013)

Individuals with a substance use problem often seek or are urged by family, friends and/or colleagues to “get treatment” –as if this encompasses a standard protocol with expected outcomes. This could not be further from the truth. Miller and Heister (2002) ranked 43 different treatments by analyzing 217 published clinical research trials, and concluded that “it is the treatments with the worst clinical records that are almost universally employed by programs”.

Schaler (1996, 2002) looked at the difference between medically-driven therapies that define ‘addiction’ as a disease or disorder, and behaviorally-driven therapies that define ‘addiction’ as a coping mechanism for dealing with life experience:

Under the MEDICAL MODEL, everyone gets the same therapy, the patient is urged to accept the ‘addict / alcoholic’ identity, therapies and cures are dictated TO the patient, there is a ‘diagnosis’ using medical criteria, patients must accept or realize ‘symptoms’ –patients claiming alternative views are labelled as ‘in denial’, patient is taught he has no control or choices, the treatment focus is on the ‘addiction’ rather than life problems, total abstinence or a strict regimen of on-going medication are the only solutions, primary social supports are fellow peers, the same treatment or group support lasts forever, ‘addict identity’ is forever.

Under the BEHAVIORAL MODEL, drug use is viewed as a way of coping with life experiences, treatment is varied and designed to fit the individual, focus is on life problems to resolve rather than on learned acceptance of an ‘addict identity’, patient is assisted in creating their own goals and therapy plans, drug use is viewed as a situational phenomenon rather than an uncontrollable life-long prognosis, patient defines negative consequences for themselves, positive images of self are accepted at face value, the need for control and making choices is fostered, the treatment focus is on the environment, improved self-control and self-management are taught, primary social supports are friends and family or co-workers, the ‘right’ treatment or group support is ever-evolving, recognition of the ability to ‘outgrow’ the need for drug use, view of self as a lifelong ‘addict’ is negated.

Therapies for ‘addiction’ span the range between these medical and behavioral models. Some therapies can be used in tandem with pharmacological treatments for substance use and co-occurring disorders, while others were designed specifically for individuals seeking the path of abstinence. Many therapies can be applied in either individual or group sessions.

Recently, Maryland’s Behavioral Health Administration has been influenced by proponents of the medical model –most notably individuals who profit from prescribing pharmaceuticals, and have sought to fund ONLY recovery programs that rely on pharmacological approaches, while denying funds to those programs which utilize abstinence-based behavioral approaches. This trend seeks to limit or remove the choice that consumers can make regarding their own personal recovery journey.

Some therapies that have been used successfully in treating problematic substance use include:

12-Step Therapy, also known as the Minnesota Model (named for a Minnesota hospital in the 1950’s where it was first used), is based on the therapist actively encouraging and facilitating the patient’s attendance at 12-step meetings, tracking the patient’s participation, and discussing common 12-step themes. Abstinence from all drugs has historically been the goal, and post-acute withdrawal symptoms, such as cravings, are mitigated through drug-free alternatives, including social support, distraction, ‘urge-surfing’, journaling, self-talk, and other strategies. The primary goal is to involve patients in these mutual-support organizations within their community. (For sources on the efficacy of 12-Step Therapy, see pages 48-57)

Social Skills Training targets interpersonal communication, regulating one’s emotions, problem-solving and organization. Individuals learn new strategies and skills for coping with stressful situations, dealing effectively with relationships, avoiding risky situations, and creating new recreational pastimes. They receive assistance with setting long-term goals, replacing drug-using with healthy activities, and identifying and adapting cultural norms. Assistance with identifying and developing vocational and/or educational goals and plans is also targeted. In essence, the therapist assists the individual with re-establishing healthy connections with family and community. (For sources on the efficacy of Community Connection, see pages 40-41)

Cognitive Behavioral Therapy (CBT) challenges dysfunctional or destructive thought patterns about oneself or the external environment that lead to mood disorders –particularly depression and anxiety, and inevitably to harmful substance use. It focuses on current problems and potential solutions, as opposed to analyzing past experiences or trauma that may be at the root of the problem. A central element of CBT is anticipating likely problems and enhancing patients’ self-control by helping them develop effective coping strategies. Specific techniques include exploring the positive and negative consequences of continued drug use, ‘self-monitoring’ to recognize cravings and risky situations early, and developing strategies for coping with cravings and avoiding high-risk situations. CBT is effective in reducing opiate use and relapse (Pan et al, 2015), and in addressing co-occurring substance use and depression (Baker et al, 2010; Bayles, 2012; Cornelius et al, 2011; Hides et al, 2010; Hunter et al, 2012; Osilla et al, 2009; Recovery Research Institute, 2018; Riper, 2013; Watkins et al, 2011).

Relapse Prevention (RP) is similar to CBT, but focuses more on identifying the high-risk situations in which the patient is likely to use substances and the steps that can be taken to avoid or prepare for them. These situations are caused when any one of a range of seemingly innocuous stimuli, commonly known as ‘triggers’ –emotions or stress, lack of sleep or hunger, or people or places, set off a chain reaction of thoughts that lead to using substances. These thoughts quickly grow to cravings and an overwhelming urge to use. Developing skills and strategies to avoid triggers, or experience them differently, leads to increased confidence in handling challenging situations without substances over time.

Motivational Interviewing (MI) is an approach that puts the client in charge of their own treatment objectives and goal setting, with the therapist in a supporting role. Unlike other therapies, where the therapist is the “expert” –imposing their perspective on the client’s substance use behavior and prescribing the appropriate treatment and desired outcome, the therapist seeks to understand the client’s issues, struggles, and barriers, and assumes a collaborative role in planning and prioritizing action steps. This approach recognizes that people who choose to use substances are often making rational choices that make sense to them, and that they may be ambivalent about changing –at times wanting to change and at other times not. The patient is viewed as the expert and the only individual with accurate insights into their substance use behaviors.

This approach avoids inadvertently triggering feelings of defensiveness among clients who may perceive their autonomy and freedom as being undermined, or who perceive a ‘disconnect’ between their own view of the problem and solution, and the therapist’s. Clients are encouraged to talk about their reasons for using substances from their point of view –with the understanding that there are pros and cons associated with their choices. When clients feel heard and understood, without judgment and criticism, they are more likely to honestly share their experiences and concerns in depth, and disclose their substance use and related behaviors more accurately. During further exploration, the therapist and client can begin to look at disparities between the client’s current behaviors and his or her stated goals –leading the client to consider making the often difficult changes necessary to accomplish their stated goals. The therapist never imposes or coerces changes that may be inconsistent with the individual’s own values, beliefs or wishes. MI is simply a collaborative non-confrontational approach to communicating that respects the views and values of the individual.

MI was found to be better than assessment and feedback, advice, or no treatment, with significant impact directly following the intervention, but has been found to have limited impact over time and no impact on individuals already receiving ‘treatment as usual’. (Burke, 2012; Miller et al, 2003; Smedslund et al, 2011)

Contingency Management (CM) uses a system of positive and negative reinforcement, operating on the premise that rewarded behaviors are more likely to continue, while behaviors that are punished are more likely to be reduced and eventually extinguished. In a treatment setting, patients receive rewards for desired behaviors, and are penalized or lose privileges for undesirable behaviors. A common CM methodology uses a system of vouchers as rewards for positive results –like treatment attendance or drug-free urine samples, with the value of the voucher increasing over time. When enough vouchers are collected, they can be traded in for prizes or activities. CM has been shown to be particularly effective for substance use disorder, as well as impulsivity and defiance (Patterson, 2018). However, there is evidence that the treatment benefits dissipate once the rewards are no longer available (Lee and Rawson, 2008).

Community Reinforcement Approach (CRA) is similar to CM in that it focuses on altering factors within the environment in order to make sober behavior more rewarding than substance use. This only works when the environment of the patient can be consciously manipulated by someone who is able to influence it –such as within a family structure or marriage (see CRAFT, p. 74). This treatment relies on the assumption that important relationships are negatively impacted by substance use and that distress within the relationship can lead to increased substance use. The focus involves improving the partner’s or the parent’s ‘coping strategies’ in substance-related situations, and teaching interventions which lead to improved familial or partner relationships. The partner or parent is trained in strategies to reinforce desired behaviors and to impose consequences for undesirable behaviors, while practicing positive communication skills, recognizing their loved one’s positive qualities, and scheduling mutually pleasurable non-drug activities. Aligning the patient’s home environment and family support system in positive treatment enhancement has been shown to be highly successful. (Foote, et.al. 2014; Partnership for Drug-Free Kids, 2015)

Trauma-Informed Care has been identified as one of the greatest lacks within current treatment programs, despite the fact that it is a highly significant factor in co-occurring substance-use disorder (Mate 2010). Trauma at any point in one’s life greatly increases the odds for problematic substance use and addiction. Childhood trauma caused by abuse, chronic adversity, and major negative life events are associated with high levels of drug use (Anderson, 2013; Sinha, 2009). Studies show that the greater the number of traumatic incidents that the individual experiences, their propensity for addiction increases. Trauma decreases the amount of oxytocin produced in the brain –the chemical responsible for love, empathy and bonding, while releasing cortisol –the chemical responsible for stress. Over time, the individual learns to view the world through a ‘stress filter’ rather than a ‘love filter’, and react accordingly –expecting and thus perpetuating stressful and toxic situations. They inevitably find that various substances calm and soothe them in ways not formerly available to them, and begin to self-medicate.

Addiction treatment should be trauma sensitive. Unfortunately far too much of addiction treatment found in the U.S. serves only to further traumatize individuals. (Fletcher 2013)

SMART Recovery is an addiction recovery support group that teaches self-empowerment strategies and techniques for self-directed change. Similar to the AA/NA ‘fellowship’, participants learn tools for recovery and participate in a world-wide community which facilitates both community-based and online meetings.

The SMART Recovery 4-Point Program® offers tools and techniques for each program point: 1) Building and Maintaining Motivation; 2) Coping with Urges; 3) Managing Thoughts, Feelings, and Behaviors; and 4) Living a Balanced Life

SMART Recovery outwardly supports the use of psychological treatments and legally prescribed psychiatric and addiction medication.

Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are the two most well-known 12-step recovery programs for people suffering from substance use disorder.  Participants attend meetings with other individuals in recovery and share their challenges and successes.  The program promotes a set of guiding principles and a course of action designed to assist individuals in abstaining from problematic substances.  Individuals are assisted in coping with challenges and supported through the ‘rough spots’ associated with their recovery through the mutual support of their peers who have years of successful recovery under their belts.

The ‘program’ was developed in 1935 by two individuals –Bill Wilson and Dr. Bob Smith, who suffered from chronic alcoholism.  It consists of working through twelve progressive steps and adhering to twelve traditions that are outlined in the Big Book –referred to as the ‘A.A. bible’.

The 12-Steps of Alcoholics Anonymous

1) We admitted we were powerless over alcohol—that our lives had become unmanageable.
2) Came to believe that a Power greater than ourselves could restore us to sanity.
3) Made a decision to turn our will and our lives over to the care of God as we understood Him.
4) Made a searching and fearless moral inventory of ourselves.
5) Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6) Were entirely ready to have God remove all these defects of character.
7) Humbly asked Him to remove our shortcomings.
8) Made a list of all persons we had harmed, and became willing to make amends to them all.
9) Made direct amends to such people wherever possible, except when to do so would injure them or others.
10) Continued to take personal inventory and when we were wrong promptly admitted it.
11) Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12) Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Medication-Assisted Recovery Support (MARS) is a 12-Step Program for individuals who choose to follow a medication-assisted recovery program.  Some traditional 12-step meetings are based on maintaining abstinence from all addictive substances, regardless of whether they are illicit or prescribed.  The participants at these meetings are philosophically unable to support individuals following a harm-reduction path that includes the use of physician-prescribed and monitored medications.  MARS provides a mutually supportive recovery environment for those participating in harm-reduction alternatives where individuals can discuss issues related to their personal choices and individualized path to recovery.  Their philosophy rests on the premise that while medications cannot cure dependence on drugs or alcohol, some play a significant and lifesaving role in helping people to begin and sustain recovery.

A Black Box Warning for 12-Step Based Treatment

Black Box Warnings are used in labelling prescription drugs or products by the Food and Drug Administration (FDA) when there is “reasonable evidence” of an association of a serious hazard with the drug, as in the prescribing of methadone.  Unfortunately, we do not have a similar label for treatment industry therapies and interventions; otherwise those providers which employ primarily 12-Step philosophies, especially to the near total exclusion of other evidence-based solutions, would come with a ‘Black-Box Warning’, according to more than 80 years of research.

The research shows that 12-Step based treatment is highly beneficial for a small percentage of individuals (5%-10%), while being ineffective at best or extremely harmful at worst, for the majority of individuals who attend (academicmisconceptionsofaainoz.weebly.com, 2013; Dodes and Dodes, 2014; Glaser, 2017; Mohr, 2007, 2011; Peele and Bufe, 2000).  Only about 26%-31% of those who begin A.A./N.A. are still attending after a year, and that number drops down to 14%-18% at the 18 month mark.  Of the 14%-31%, still engaged in the program, only between 21% (Fingarette; Harris, 2003) to 40% (Fiorentine, ) of attendees maintain sobriety –meaning that out of the total population of people who ever begin A.A./N.A., only 5%-8% are able to achieve and maintain sobriety for longer than one year.  (Dodes, 2014; Fingarette, ; Harm Reduction Network, 2009; Harris, 2003; Mohr, 2007, 2011; National Longitudinal Alcohol Epidemiologic Survey, 1992; Whittington, 1994)

For those who do succeed in 12-step programs, their success correlates with several factors, including active involvement rather than simple attendance (attendance alone shows minimal correlation with lower rates of substance use); developing a strong bond with a suitable sponsor, or more importantly, being a sponsor (Crape et al, 2002; Kelly et al, 2016; Pagano, 2004); and developing a sense of belonging and group affiliation (Flora et al, 2010; Groh et al, 2008; Krentzman et al, 2010; Laudet, 2008).  In a survey of patients undergoing treatment, Laudet (2008) reported that the two most common reasons given for attending AA/NA were to promote recovery and sobriety, and to find support, acceptance and friendship.

Claims that 12-Step programs are beneficial for all who suffer with addiction are often refuted by opponents, citing evidence that shows the rate for ‘spontaneous remission’ (p. 66-67) is the same or higher than the success rate for AA/NA. Spontaneous remission refers to the percent of individuals meeting medical criteria for having a substance use disorder who achieve either abstinence or safe substance use on their own without any intervention other than their own volition –after all, even the most addictive substance can be tapered off gradually over time. (Coy, 2010; Dodes and Dodes, 2014; Mohr, 2007, 2011; Peele, 2010; Dawson, 2005; Johnson, 2010; Stewart, 2015) If the success rate for AA/NA is lower than the rate for spontaneous remission, that would indicate that AA/NA actually has a harmful effect, causing increased substance use in cases that would not have occurred otherwise. There seems to be ample evidence to support the theory that AA/NA dropouts do worse than those who seek no treatment at all.

A Cochrane review of eight trials comparing AA/NA to other psychosocial interventions found that no experimental studies unequivocally demonstrated the effectiveness of Twelve Step Facilitation approaches in reducing dependence or substance-related problems. (academic misconceptionsofaainoz.weebly.com, 2013; Ferri, 2006)

Despite scientific and anecdotal evidence that simply attending AA/NA does not correlate with lower rates of substance use or successful recovery (Kownacki and Shadish, 1999), it is curious that 12-Step programs have become such an integral part of providers’ treatment regimens –as high as 90% use 12-Step indoctrination (Kelly, 2011), and that so many judges rely on these potentially ineffective, if not outright dangerous programs, for their court-ordered clients. (Glaser, 2017; Mohr, 2007, 2011; Peele and Bufe, 2000; Wendland, 2014) Out of the total 12- Step attendees, reports estimate that approximately 36% are court ordered (Wendland, 2014) and many more are forced to attend as a condition of treatment.

–it means that the medical profession and the court system in the United States are each year directing thousands of sick people into a program that has little or no merit as a treatment for their illness. (Author and former 12-stepper, Stephen Mohr, 2007, 2011)

Maryland’s 12-Step Treatment – Helping or Harming?

Two thirds of all residential detox providers (ASAM 3.3 to 3.7) in Maryland report that they require their patients to attend 12-Step meetings EVERY DAY, while ALL Maryland providers offering this level of care require weekly patient attendance –2-5 times per week.

The Perpetration of Harm

The ‘Powerless and Unmanageable’ Rationale:

A study measuring binge drinking in court offenders found that alcoholic men who attended AA became 9 times more likely to subsequently “binge drink” than those who participated in cognitive behavioral therapy. They were also 5 times more likely to binge than those who received no intervention (Brandsma, 1980). DUI offenders coerced into attending AA/NA had similar results.

One possible explanation for an increase in binging is that participants may come to believe 12-Step dogma predicting the probability of an inevitable and immediate loss of control after one drink (or even a rum ball or swish of mouthwash containing alcohol). If members are taught that they have absolutely no control over their substance use and that their ‘disease’ is so progressive and chronic that a single whiff or sip of something may send them on an uncontrollable rampage of substance use, this may indeed become a self-fulfilling prophecy. (academicmisconceptionsofaainoz.weebly.com, 2013; Glaser, 2017; Peele and Bufe, 2000; Slate, 2010)

If individuals fail to perceive that self-control and moderation even exist, how can they be expected to learn how to practice it? When relapse does occur, there is a tendency toward fatalism –“I am powerless. I can’t stop. God did not help me out this time.” There next logical thought may easily be, “I am hopeless and inferior—even worthless.” (Dodes and Dodes, 2014; Johnson, 2010; Mohr, 2007, 2011; Peele and Bufe, 2000; Perkins, 2016; RationalWiki.org, 2017; Sexson, 2002)

The ‘Turning Lives Over to the Care of God’ Rationale:

For many who have no concept of God or how “turning one’s life over to God’s care” might be accomplished, it remains a vague and incomprehensible concept (Morrow, 2017).  What’s even more confusing is that many attendees are told to substitute anything for God –even inanimate objects (Mohr, 2007, 2011).  Obviously, even those most desperate for a way out of their addiction will find little promise in the belief that a random ‘power’, object or deity of their choosing can intervene in behaviors which they have found difficult to control.  It is not until the final two steps that attendees are perhaps pointed in a direction toward developing a deeper spirituality and an understanding of the divine.  One could argue that unless these last two steps are accomplished, then suggestions regarding turning one’s life over to God, implicit in the prior steps, will seem meaningless and futile to those without a prior experience of spirituality (academicmisconceptionsofaainoz.weebly.com, 2013; Stewart, 2015).

Miller (2009) found that patients who received spiritual guidance as the main treatment component –practicing prayer, meditation and service to others (similar to the 12-step model), were more anxious and depressed after four months than those who received secular psychotherapy –cognitive behavioral therapy or mindfulness-based acceptance and commitment therapy.

By perceiving personal powerlessness and turning over their recovery (and any subsequent gains made) to an almighty deity, members can lose their capacity to recognize all of the other external and internal factors that tend to keep them sober –such as an honest desire to be healthy again or the love and support of their families, and fail to build upon their own personal strengths and successes. (Dodes and Dodes, 2014; Mohr, 2007, 2011; Morrow, 2017; Peele and Bufe, 2000; Perkins, 2016; RationalWiki.org, 2017; Schaler, 1995; Stewart, 2015)

The ‘Denial’ Rationale:

Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. (Chapter 5 in the Big Book, www.aa.org)

This quote from Chapter 5 of the Alcoholics Anonymous –Big Book, sets up a ‘you’re either with us or against us’ paradigm –a judgmental and demeaning choice for the individual struggling to gain a foothold in recovery. They either must identify as a lifelong “addict”, needing and willing to follow the AA/NA path, or be labelled as “in denial”, helplessly flawed and incapable of being honest –“born that way”. There are no other choices. This confounding dichotomy forces attendees into a culture that many describe as “shame-based, fear-based, and guilt-inducing”.

Voice of a Veteran 12-Stepper: This might ring alarm bells were most AA newcomers not lost in a fog of despair to get well. Alone and outnumbered amongst indoctrinated strangers whose help they need, most raise no outward objection to this convoluted (and completely untrue) jargon. Non-sufferers, with more clarity, consider this a judgmental and demoralizing alternative. (academicmisconceptionsofaainoz.weebly.com, 2013)

The underlying message is –“either follow our non-clinical layman’s formula for addressing your chronic and often fatal healthcare problem or acknowledge that your character is so flawed that you must resign yourself to failure and ultimately death.” (academicmisconceptionsofaainoz.weebly.com, 2013; Alexander and Rollins, 1984; Glaser, 2017; Johnson, 2010; Mohr, 2007, 2011; Morrow, 2017; Peele and Bufe, 2000; Perkins, 2016)

The notion that drug use somehow turns Dr. Jekyll into Mr. Hyde, that it gives people ‘addict personalities’ and turns them into pathological liars and causes them to suffer from ‘denial’ and other ‘character defects’ is belied by all empirical evidence… Research clearly demonstrates that people who are physically dependent on a substance are no more likely to lie then a general sample of the population. Research has also demonstrated that people who suffer negative consequences from drug use do not deny it to themselves. What causes denial is not drug use; it is incompetent drug treatment techniques. (Anderson, 2013)

Confrontational counseling causes people to lie. In fact, the confrontation leads people to lie whether they are drug users or not. Likewise, the threat of taking away something which an individual value will cause most individuals to lie, as will the threat of pain, regardless of whether that individual uses drugs or not.

There has never been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes. (Miller and White, 2007)

Defensiveness is a normal human response when one is accused, demeaned, labeled, disrespected or threatened. Confronting evokes client defensiveness, which in turn appears to confirm the diagnosis and bolsters the belief that such clients are typically defensive and intransigent. Clinical experiments have demonstrated that clients’ levels of resistance are very much under the control of the counselor, and influenced by therapeutic style. Counselors can drive resistance up and down within the same session and client, simply by switching back and forth between a directive-confrontive and a listening-supportive style. (Anderson, 2013)

Additionally, it has been noted that rehabs teach people how to act like addicts and adopt many behaviors which they did not have before rehab (Anderson, 2013; Fletcher 2013; Szalavitz 2010). Adopting the ‘in denial’ persona may likely be one of them (see page 43: Fostering the Addict Personality).

The ‘Rock Bottom’ Rationale:

Program dropouts (90% within the first 3 months) are accused of failing to “work the program”, “wanting” to return to substance use, and “not wanting” help to get better.  It is assumed under this misleading doctrine that those who have not achieved success simply were “not ready to get better yet”, or that they haven’t “hit rock bottom”, rather than that they have not yet received the appropriate treatment to address underlying neurological, mental or emotional problems.  This leads to a misplaced perception of self-blame, sense of failure, loss of hope, depression, and other negative feelings that may ultimately contribute to increased use.  Successful 12-steppers often inadvertently create a feeling of hopelessness in the very people they purport to be helping by expressing an ‘if I can do it, therefore you can do it’ mentality, with little knowledge of the individual’s past experiences, neurological chemistry, history of trauma, developmental and/or cognitive capacity, or perceptions of self-worth.  There is little discussion surrounding the idea that underlying mental, emotional, or trauma based issues may actually be at the root of their substance use.  (academicmisconceptionsofaainoz.weebly.com, 2013; Glaser, 2017; Perkins, 2016)

The ‘Moral Inventory’ of a ‘Wrong’ and ‘Defective Character’ Rationale:

Blaming substance use on a flawed morality, wrong actions, and a defective character paints the vulnerable individual in early recovery as guilty and shameful. (academicmisconceptions ofaainoz.weebly.com, 2013; Mohr, 2007, 2011; Morrow, 2017; Ragge, 1998, 2000) This tact fails to recognize that substance use is often a very logical, reasonable and effective mechanism for coping with trauma, mental health symptoms, or overwhelming feelings of helplessness or hopelessness. The program mantra “your best thinking got you here”, is meant to diminish the patient’s past choices and thought processes, rather than provide the patient with insights into exactly how and why their choices, which may have been their best logical response to coping with overwhelming feelings, got them to the point where they are. Blaming their choices on a ‘defective character’ does not readily offer options for exploring different ways of coping with a myriad of problems –mental health symptoms, recurrent memories of trauma, or stored emotional pain; or behavioral problems, such as poor impulse control; or social problems, such as acute shyness or loneliness. Recognizing that one’s choices were simply ineffective ways of coping with very real problems, and that through learning and practicing healthier alternatives, problems can be overcome without the use of substances, may be a better choice. (Mohr, 2007, 2011; Peele and Bufe, 2000; Ragge, 1998; RationalWiki.org, 2017; Stewart, 2015)

Critics also point out that ‘the moral inventory’ is typically a fearless searching of negative attributes that can perpetuate feelings of self-loathing and low self-esteem. There is no mention of conducting a strengths-based self-assessment in the AA/NA literature.

Voice of a Veteran 12-Stepper: –the only items had to be shortcomings, character flaws, and moral defects – no room for any positives. (Gilliam, 1998)

The Sponsor-Sponsee Relationship:

The basis for successful recovery works on the premise that members who have successfully achieved recovery become mentors (sponsors), helping newly initiated members to follow in the same path.  Sponsors are deemed eligible to provide mentoring and guidance to newcomers, simply by achieving some measure of sobriety.

While some studies have shown that having a suitable sponsor can mimic the benefits of the therapeutic alliance that exists between therapist and patient (Kelly et al, 2016), other studies have indicated that having a sponsor was not associated with any improvement in 1-year sustained abstinence rates than a non-sponsored group. However, being a sponsor over the same time period was strongly associated with substantial improvements in sustained abstinence rates for the sponsors (Crape et al, 2002). This suggests that sponsorship is only to the sponsor’s advantage, not the sponsee’s (Crape et al, 2002; Dodes and Dodes, 2014; Pagano, 2004; Sexson, 2002)

These mentors are typically untrained and unqualified. They operate under no accountability or control standards of any kind, some inevitably affected by mental health conditions, either diagnosed or undiagnosed, managed or not. Some sponsors are renowned for breaking up marriages and families and have made world news in recent years after sexually exploiting vulnerable newcomers, as any quick internet search will confirm. …Its luck-of-the-draw as to just how sane and functional, controlling and unbalanced, knowledgeable or ill advising [the sponsor] will turn out to be over time. Anecdotal evidence is rife of resentful, compulsive ex-sponsors harassing, even stalking, members who chose to leave AA. (academicmisconceptionsofaainoz.weebly.com, 2013)

Therapists are left to unravel the mental, emotional, and physical harm perpetrated on vulnerable patients, newly in recovery, by codependent and abusive sponsors. (academicmisconceptionsofaainoz.weebly.com, 2013; Ragge, 1998, 2000; Summers, 2007)

The Unofficial 13^th Step:

“Thirteenth-stepping”, a disparaging AA euphemism referring to sexual exploitation of vulnerable newcomers, has been documented in professional journals as well as Newsweek and The Washington Post. The apparently common practice of veteran members sexually harassing or seducing new members, particularly women, is so prevalent that one can find literally thousands of references to it on the internet.  According to professionals, whose client stories abound with horrific tales of sexual and emotional abuse, these predators are not seeking to establish a healthy functional relationship but merely fulfilling an unhealthy and unaddressed need for control and dominance.  (academicmisconceptionsofaainoz.weebly.com, 2013; Bogart & Pearce, 2009; Dodes and Dodes, 2014; Kasl, 1992; McGuiness, 2011; Morrow, 2017; Ragge, 2000; RationalWiki.org, 2017; Richardson, 2015; Riley, 2012; Stewart, 2015)

In one survey designed to elicit women’s experiences with 13^th-stepping, results showed that at least 50% of the participants had at least occasionally experienced seven of the thirteen 13th-stepping behaviors listed in the survey (Bogart & Pearce, 2009).  Dr. Ellen Dye, a Maryland-based psychologist who has treated members from a Bethesda chapter where 13^th stepping was so ingrained within the chapter’s culture that it prompted a 2007 news report, is quoted, “A lot of the people coming into recovery are vulnerable. They don’t have great boundaries, and if they go into a group and feel alienated or violated, it’s very hard for them to go back in.” (Summers, 2007)

Abstinence vs. Harm-Reduction:

Historically, the AA/NA ideology is based on supporting members in achieving sobriety through abstaining from all narcotic medications. (academicmisconceptionsofaainoz.weebly.com, 2013; Glaser, 2017; Mohr, 2007, 2011; Morrow, 2017)

The traditional view is that taking even one drink or one drug is like lighting a fuse to a bomb that lies dormant in the limbic system just waiting to explode into full-blown addiction again with the first rush of dopamine into the nucleus accumbens. The problem with this picture is that it does not fit the empirically observed facts but rather fits in with a lot of mythology created by AA and the treatment industry. (Anderson, 2013)

With any substance use, some people find it easier to cut back and control their use than attempt to stop altogether because they feel deprived when abstaining totally. This drives them to go on uncontrolled benders that quickly escalate. Convincing someone who is successfully controlling their substance use to switch to an abstinence goal does not necessarily produce the most favorable outcome. With opioid dependence, some people succeed best with abstinence, while others succeed best with opioid maintenance therapies. One size does not fit all. (Anderson, 2013)

Individuals taking medication for psychotic disorders –schizophrenia, bipolar, depression, have been urged to discontinue their medication by other AA/NA members. “[Reports of] suicide, serious damage to personal confidence and psychotic breakdown are not uncommon” (Rounsenfell, 2013). A 2000 study entitled, Alcoholics Anonymous and the Use of Medications to Prevent Relapse: An Anonymous Survey of Member Attitudes, systematically assessed AA members anonymously about their attitudes toward use of medication for preventing relapse and their experiences with medication use of any type in AA. Nearly a third of the subjects reported personally experiencing some pressure to stop a medication (of any type), and of those, nearly a third stopped taking a prescribed medication based on this advice. (Rychtarik et al, 2000)

A Culture of Cultism:

Some researchers present evidence that A.A./N.A. exhibits the characteristics of a cult.  (academicmisconceptionsofaainoz.weebly.com, 2013; Alexander and Rollins, 1984; Kenney, 1998; Mohr, 2007, 2011; Morrow, 2017; Perkins, 2016; Ragels, 2017; RationalWiki.org, 2017; Schaler, 1995; Sexson, 2002; Summers, 2007)  Charlotte Davis Kasl, Ph.D, author of Many Roads, One Journey: Moving Beyond the 12 Steps (1992), notes unhealthy cult-like characteristics that dominate the program’s culture:

1. The group discourages or blocks outside involvement.
2. The group limits or discourages access to reading material or other forms of personal growth.
3. Expression of dissension is punished, squelched, or strongly discouraged.
4. The group becomes grandiose in its self-definition — “Ours is the one way, the road to salvation.”
5. Members become locked into stereotyped roles.
6. The group becomes paranoid about outsiders or those who question the norm.
7. Members begin to speak robotically.
8. In-group jargon predominates in conversations.
9. The group exerts pressure on people to stay.
10. Members use the group for sexual needs.

The ‘Family Illness’ Rationale:

Cessation of drinking is but the first step away from a highly strained, abnormal condition. A doctor said the other day, ‘Years of living with an alcoholic is almost sure to make any wife or child neurotic. The entire family is, to some extent, ill.’ (Chapter 9 –Big Book, www.aa.org)

In a critique of AA/NA, Ragels (2009) argues that defining the entire family as being ‘sick’undermines family relations by causing the AA/NA newcomer to doubt their support system. The ‘family sickness’ illusion is used as a wedge to separate the individual from their family, providing further evidence of the cult mentality mentioned previously. AA/NA members report being told by sponsors or other group members that affiliation with the group is more important than family connection and responsibility, (academicmisconceptionsofaainoz.weebly.com, 2013; Alexander and Rollins, 1984) and the complimentary 12-Step family support group –Nar/AlAnon, promotes a ‘detach with love’ philosophy as well (See page 70). (Ragels, 2009, 2017)

Benefits

• Participants enrolled in a formal treatment program and attend 12-step programs simultaneously, stay in formal treatment programs longer, are more likely to complete a formal treatment program, and are more likely to remain abstinent than those in a 12-step program alone, or in a treatment program alone (Fiorentine and Hillhouse, 2000; Kelly, 2011; Krentzman et al, 2010)

• Providing social networking opportunities with peers who have similar lived experience, can offer emotional support, validation, hope and awareness (Flora et al, 2010; Groh et al, 2008; Laudet, 2008; Perkins, 2016), and the experience of bonding with others in a room can promote the release of oxytocin in the brain, creating a sense of well-being (Stewart, 2015)
• The sponsor-sponsee relationship has the potential of mimicking the same therapeutic alliance that is often developed between therapist and patient, with similar benefits (Kelly et al, 2016), and being a sponsor or helping another person to maintain their sobriety is associated with an increased likelihood of maintaining sobriety for the sponsor (Crape et al, 2002; Pagano, 2004)
• Reciting prayer (such as the serenity prayer) in A.A./N.A. meetings is associated with a reduction in self-reported craving, and also with increased neural responses that reflect control of attention and emotion (Galanter et al, 2016; Sussman, 2011)

Risks

• Success rate for remaining sober for those entering 12-step programs is between 5%-10% –less than the rate for spontaneous remission (Dodes, 2014; Johnson, 2010; Mohr, 2007, 2011;  Morrow, 2017; Peele and Bufe, 2000; Sexson, 2002; Stewart, 2015)
• Forcing patients in the treatment and/or justice system to attend a program with a success rate for remaining sober that is between 5%-10% is misguided, potentially damaging, and detrimental  (academicmisconceptionsofaainoz.weebly.com, 2013; Alexander and Rollins, 1984; Dodes, 2014; Glaser, 2017; Mohr, 2007, 2011;  Morrow, 2017; Peele and Bufe, 2000; RationalWiki.org, 2017; Sexson, 2002; Stewart, 2015)
• Evidence demonstrates that participation promotes increased drug and/or alcohol consumption, particularly binging (academicmisconceptionsofaainoz.weebly.com, 2013; Brandsma et al, 1980; Ditman et al, 1967; Glaser, 2017; Peele and Bufe, 2000; RationalWiki.org, 2017)
• Underlying neurological, mental or emotional needs are typically not viewed as the issue, and are therefore not addressed (academicmisconceptionsofaainoz.weebly.com, 2013; Dodes and Dodes 2014; Glaser, 2017; Kenney, 1998; Morrow, 2017; Peele and Bufe, 2000; Perkins, 2016; Sexson, 2002)
• Blaming an individual’s failure to achieve sobriety solely on the individual, rather than on a treatment system failure to address underlying causes, is psychologically harmful (Alexander and Rollins, 1984; Dodes and Dodes, 2014; Glaser, 2017; Hester and Miller, 2003; Johnson, 2010; Mohr, 2007, 2011; Peele and Bufe, 2000; Perkins, 2016; RationalWiki.org, 2017; Stewart, 2015)
• Rhetoric perpetuates the myth of lifelong illness without permanent recovery, which is not supported by science (academicmisconceptionsofaainoz.weebly.com, 2013; Dodes and Dodes, 2014; Glaser, 2017; Kenney, 1998; Mohr, 2007, 2011; Peele and Bufe, 2000; Perkins, 2016; RationalWiki.org, 2017; Sexson, 2002)
• A belief in being powerless, insane, and having a lack of control over one’s own behaviors and compulsions prevents the utilization of a strengths-based approach, which has been associated with better outcomes and shown to be more effective in bringing about change in therapeutic populations (academicmisconceptionsofaainoz.weebly.com, 2013; Coy, 2010; Gilliam, 1998; Morrow, 2017; Peele, 2010; Perkins, 2016; RationalWiki.org, 2017)
• The 12-steps are grounded in Christianity (six steps refer to God), and as such may be offensive to individuals who practice other religions, or who lack a spiritual base from which to relate to these steps, or who are atheist. (Mohr, 2007, 2011; Morrow, 2017; RationalWiki.org, 2017; Sexson, 2002; Stewart, 2015). Furthermore, the idea that members are advised to relinquish control over their life to their ‘higher power’, puts them in a position of subjugation to the divine, rather than one of collaboration or co-creation –thereby contradicting some spiritual teachings (Morrow, 2017).
• Without a process for vetting members, vulnerable new members struggling with new found emotions and the symptoms of chemical imbalances associated with early recovery, are mixed with individuals who may have severe and unaddressed mental health problems that cause them to prey upon these more vulnerable members (academicmisconceptionsofaainoz.weebly.com, 2013; Kenney, 1998; Morrow, 2017; Sexson, 2002; Summers, 2007)
• 13th-stepping –sexual exploitation of vulnerable newcomers, can cause the victim to feel alienated or violated (Bogart & Pearce, 2009; Coy, 2010; Dodes and Dodes, 2014; Kasl, 1992; Morrow, 2017; RationalWiki.org, 2017; Stewart, 2015; Summers, 2007)
• Individuals who take medications for psychological conditions or who choose a harm reduction model for their recovery (medication-assisted treatment) are sometimes stigmatized by those choosing the abstinence-based model traditionally promoted by A.A./N.A. (Glaser, 2017; Morrow, 2017; Rounsenfell, 2013; Rychtarik et al, 2000)
• Harmful, demeaning and judgmental labels are common and difficult to escape, creating feelings of low self-worth (academic misconceptions ofaainoz.weebly.com, 2013; Alexander and Rollins, 1984; Mohr, 2007, 2011; Morrow, 2017; Perkins, 2016; RationalWiki.org, 2017; Schaler, 1995; Sexson, 2002; Summers, 2007)
• The fellowship of AA becomes the replacement social network, and links to other social networks are often discouraged –including friends and family, regardless of whether these networks were a positive influence or not (academicmisconceptionsofaainoz.weebly.com, 2013; Alexander and Rollins, 1984; Johnson, 2010; Kenney, 1998; Mohr, 2007, 2011; Morrow, 2017; Ragels, 2017; Sexson, 2002; Summers, 2007; Sussman, 2011)
• Leaving the group, regardless of the very personal and many times healthy reasons, can still trigger feelings of depression or anxiety (Giles, 2014; Perkins, 2016; Summers, 2007)
• Treatment programs are pitching a self-help cure for a condition that is medical, psychological and behavioral with little regard for whether their approach actually solves problems or helps anyone (academic misconceptions ofaainoz.weebly.com, 2013; Glaser, 2017; Mohr, 2007, 2011; Morrow, 2017; Peele and Bufe, 2000; Wendland, 2014)

While there is a lack of scientific research regarding the direct impact of spirituality on recovery from addiction, there is some related evidence that is worth considering. Historically, medicine and spirituality were intertwined. A growing number of studies are swinging the pendulum back by revealing the interconnectedness of the spiritual and physical realms once again, and demonstrating a much more significant role for spirituality in the healing process than the medical community had previously thought–particularly the positive contribution spirituality can make to mental health. (Cornah, 2006; Dein et al, 2010; Mental Health Foundation, 2018; Phelan, 2017; Timms et al, 2014; UMMC, 2018; Verghese, 2008)

The technological advances of the past century tended to change the focus of medicine from a caring, service-oriented model to a technological, cure-oriented model… However, in the past few decades physicians have attempted to balance their care by reclaiming medicine’s more spiritual roots, recognizing that until modern times, spirituality was often linked with health care. Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. (Puchalski, 2001)

Studies are finding that patients perceive a direct correlation between spirituality and their mental health. In one study, 79% of patients rated spirituality as very important, and 82% believed that their “therapists should be aware of their spiritual beliefs and needs”, 69% reported that their spiritual needs should be considered in their treatment plans, and 67% said that their spirituality “helped them cope with their psychological pain”. In essence, a majority of patients desire a spiritual component as part of their treatment (D’Souza, 2002; Kliewer, 2004).

Findings suggested the need for practitioners to strive to become more aware of clients’ religious/spiritual beliefs and related concerns, to understand their relevance, and to take collaborative action on the basis of this knowledge. (Castell, 2013)

Research demonstrates largely positive associations between religiosity and well-being, and that the integration of spirituality into treatment for mental health disorders, including substance use, may enhance recovery. (Dein et al, 2010; D’Souza, 2002; Koenig, 2008; UMMC, 2018; Verghese, 2008) In an extensive review of scientific journals, The International Center for the Integration of Health and Spirituality (ICIHS) concluded that spirituality is a positive factor for preventing illness, coping with illness, aiding in treatment, and improving outcomes. Similarly, in a scientific literature search by Koenig et al (2008), where the impact of spirituality could be classified as positive, negative, no association, complex, or mixed, 70% showed a strong positive impact, while only 5% showed a negative impact.

Spirituality / religious experience is a protective factor for many psychiatric and mental health outcomes – rates of mood disorder, including depression and anxiety; levels of psychological distress, including fear and insecurity; and dangerous behaviors, including isolation, suicide and substance use. Additionally, spirituality fosters a perception of life satisfaction and happiness; increases self-confidence; improves coping with stress and adversity; leads to greater social support and stabilization; and forges a sense of hope and optimism. Having a spiritual foundation has a significant and noticeable effect on overall health and healing. (Editors, 2013; Kliewer, 2004; Koenig, 2008; Levin, 2010; Rettner, 2015; Timms et al, 2014; UMMC, 2018; Verghese, 2008)

Negative emotions, like anger, resentment or fear, contribute to physical and mental illness by triggering the release of stress hormones –norepinephrine and cortisol, which accumulate in blood and build up in tissue. Sustained levels of these hormones can break down the immune system, increase risk of infection, elevate blood pressure, disrupt brain functioning, and increase risk of disease and mental dysfunction. (Cornah, 2006; Editors, 2013; Rettner, 2015; Timms et al, 2014; UMMC, 2018). A survey of 1,400 adults found that willingness to forgive oneself and others, and the perception that one is forgiven by God, had beneficial health effects, including a reduction in the build-up of these stress hormones. (Editors, 2013; UMMC, 2018)

Religious affiliation has also been shown to have a bearing on outcomes. Various religions and individual churches teach a range of coping skills for dealing with life’s ups and downs. Of 76 studies that examined the relationship between religious involvement and anxiety, 35 found significantly less anxiety or fear, 24 found no association, and 10 reported greater anxiety (Koenig, 2008). Doctrines that encourage personal empowerment, forgiveness, and life purpose, and that promote the importance of positive emotions such as hope, love, and resiliency, influence mental health in significantly positive ways, while doctrines that espouse guilt, shame, or powerlessness can be damaging or harmful to an individual’s mental health. (Cornah, 2006; Rettner, 2015; UMMC, 2018)

“If people have a loving, kind perception of God,” and feel God is supportive, they seem to experience benefits, said Kenneth Pargament, a professor of psychology and an expert on religion and health at Bowling Green State University in Ohio. But “we know that there’s a darker side to spirituality,” Pargament said. “If you tend to see God as punitive, threatening or unreliable, then that’s not very helpful” to your health, he said. (Rettner, 2015)

Those who perceive their relationship with the divine as co-collaborative show significantly greater improvements in mental health and increased involvement in recovery-enhancing activities than those who perceive a fatalistic or subservient relationship with a punitive and judgmental ‘God’ with whom they must “plead” or “bargain” with for favors. Another spiritual pillar that leads to mental resiliency is
the reinterpretation of ‘suffering’ as an emotionally strengthening, and at times necessary component in a greater life journey or pilgrimage, offering greater insights into self than would have been attainable otherwise. This worldview was found to foster hope and strength among patients with severe and chronic health conditions, as well as patients with serious mental illness. (Cornah, 2006; Kliewer, 2004)

While there is an inherent assumption in the scientific literature that spirituality and religion are simply mediating factors –and that any benefits derived from their practice must be attributable to social and psychological processes, rather than a likelihood that healing is a direct result of ‘divine intervention’, “there is no evidence to support the assumption that is all it is.” In other words, scientific research can show that religiosity alleviates mental symptoms, but researchers can only guess as to why or how this
occurs. While an attempt to create methodologies to measure ‘divine intervention’ has obvious limits, recent research has attempted to measure the impact of prayer on health outcomes. One study that examined the impact of prayer on anxiety levels in students, reported significant reductions in anxiety scores for those who were prayed for, but not for those who were not. Similar results have been replicated in other studies. (Cornah, 2006)

Mental health services should respect service users’ spirituality as a human right. A mental health service culture that responds to spiritual needs: 1) acknowledges the spirituality in people’s lives; 2) gives service users and staff opportunities to talk about spirituality; 3) encourages service users to tell staff their needs; 4) helps service users to express their spirituality; and 5) uses person-centered planning and incorporates spiritual needs. (Mental Health Foundation, 2018)

Sims makes a comment, “It is unfortunate that we as psychiatrists can be so crass as to neglect this area of life which is clearly important to many of our patients.” Andresen, in an editorial, has pointed out that our civilization’s “loss of soul” may cause psychiatric symptoms such as depression, obsessions, addictions, and violence. She has suggested that it is the responsibility of psychiatrists to remind the medical fraternity the necessity of putting back the soul in medical ethics and the fact that spirituality is of vital importance for the mental health of people. (In Verghese, 2008)

According to scientific literature, relapse following treatment occurs in an estimated 50% of patients within 6 months of treatment, and as many as 40% to 80% of these patients cycle through periods of relapse, treatment reentry, and recovery, for many years. These statistics are consistent across all ‘drugs of choice’. (Bowen et al, 2009; Enkema, 2016; Moore et al, 2014; Nauman, 2014; Partnership, 2014; Scott et al, 2005; Thompson, 2014; Zgierska, 2009) Craving, negative emotions and poor self-concept are strong predictors of the relapse process, as are stress and ruminating about upsetting experiences. These states, as well as the desire to avoid them, are primary motives for substance use relapse. MBRP is specifically designed to target these experiences and negate their roles in the relapse process.

Two elements are important in mindfulness meditation: 1) focusing attention on the immediate experience; and 2) having an accepting attitude toward that experience. Most people, not just those who have been substance-dependent, move through life on “auto-pilot” –going about daily activities out of habit while their minds are elsewhere. Mindfulness training teaches participants to focus attention on the details of the present moment. When practicing mindfulness, individuals are able to notice what they are thinking, feeling and experiencing without criticism or judgement, or most notably –reaction. (Bayles, 2014; Brewer, 2010; DualDiagnosis.org, 2018; Garland et al, 2016; Thompson, 2014; Zgierska, 2009)

This purposeful control of attention is learned through training using various mindfulness techniques and applied to preventing relapse and sustaining recovery. Patients impacted by SUDs, whose condition is often associated with unwanted thoughts, emotions or sensations, are typically oblivious to the thoughts or feelings that start a chain reaction that ends in picking up their drug of choice.

Your mind is usually focused either on how to get your substance of choice, taking steps to acquire it, using it, or recovering from the effects. Very little time and energy is spent noticing the present moment, except to try and change your experience. Indeed, the present becomes little more than a constant agitated state. (Fintzy and Jaffe, 2011)

By practicing mindfulness, patients learn to rethink stressful stimuli that would otherwise trigger a harmful train of thought ultimately leading to drinking or using. With practice, these triggers become apparent, and therefore controllable –less daunting and more manageable. The individual learns to simply ‘observe’ and accept challenging thoughts, feelings, perceptions, and circumstances without reacting to them. They learn to shift their perspective –instead of perceiving uncomfortable or un-pleasant thoughts as “real” or “true”, they can choose to view them as passing mental clouds or momentary snapshots. Acceptance of distressing thoughts makes them less potent and decreases the need to act on them –while avoiding or suppressing them has been linked to an increased sensitivity toward them and worsened outcomes (Brewer, 2011; Garland et al, 2016). In contrast to other treatment approaches –‘thought-stopping’, trigger avoidance, or reliance on ‘will power’, patients trained in mindfulness techniques allow emotionally charged thoughts or craving states to rise to the surface of their consciousness. They then reframe these experiences so they can relate to them differently. Employing ‘willpower’ to ‘fight’ or suppress these urges, often causes internal and escalating emotional stress –with the individual’s thoughts and emotions surrounding drug use actually increasing, and causing even more internal stress. As the thoughts and accompanying stress intensifies, it becomes a matter of time before relapse is inevitable. (Garland et al, 2013)

This “observe and accept” approach allows the participant to be fully present and attentive to current experience but not pre-occupied by it. Meditation becomes a mental position for being able to separate a given experience from an associated emotion. Thus, the individual is able to consider a different response to a given situation. (Zgierska, 2009)

Studies show that MBRP effectively decreases relapse rates following SUD treatment. These learned techniques become effective coping strategies, particularly when the individual finds him or herself in a high-risk situation –they are able to utilize mindfulness skills to successfully process the situa-tion calmly and end up with a different outcome than they would have previously. In clinical trials, participants in MBRP, as compared to those in other treatment modalities, report lower rates of substance use, greater decreases in craving and in negative emotions, like stress, anger, fear, sadness, insecurity, etc. (which often lead to craving). Other studies show that mindfulness meditation is an effective therapy for other mental health problems, including stress, anxiety, depression, emotion dysregulation, bipolar disorder, and PTSD, as well as for chronic pain –which are all known risk factors for relapse. Furthermore, there is evidence that mindfulness meditation may reverse, repair, or compensate for neurological changes in the brain caused by substance use –actually ‘rewiring’ a suffering brain by teaching it new and better ways to respond to problematic stimulus. Due to its proven efficacy, some treatment programs are either making mindfulness meditation a stand-alone component, or using it in conjunction with other treatment modalities. (Bayles, 2014; Bowen et al, 2009, 2013, 2014; Breslin et al, 2006; Brewer et al, 2014; DualDiagnosis.org, 2018; Enkema, 2016; Fintzy and Jaffe, 2011; Garland et al, 2013, 2014, 2016; Grow et al, 2015; Harris, 2015; Hoppes, 2006; Khusid and Vythilingam, 2018; Li et al, 2017; Nauman, 2014; Rettner, 2014; Thompson, 2014; Witkiewitz et al, 2005, 2013; Zemestani and Ottaviani, 2016; Zgierska, 2009)

Instead of getting angry over being angry, you simply notice your feeling of anger and investigate its many facets. You inhabit the moment. Yes, sitting with an uncomfortable emotion may sound about as welcoming as a sharp poke in the eye, and it certainly takes some adjustment to accept what’s going on in that moment instead of taking a mental or emotional vacation. However, by changing your relationship with your thoughts, feelings, and experiences and learning to accept them as they are, rather than how you might like them to be, you can literally change your brain and strengthen neural networks that are important in managing stress and anxiety. Over time you can develop a greater capacity for self-observation, optimism, and well-being, which can lead to better control over your addictive behavior. (Fintzy and Jaffe, 2011)

The more one practices mindfulness, the more ingrained the process becomes –and the greater control an individual has over their thoughts, feelings and perceptions –including the ‘automatic’ thoughts or motivations to use drugs. When practiced over time, the association between these triggers and drug-use may eventually be extinguished. Additionally, the techniques learned are applicable to many life situations –not just relapse prevention. Following a meditation course, 60–90% of subjects still meditated up to 4 years later, and reported that the course “had lasting value” and was “highly important” (Zgierska, 2009). Brain imaging scans showing brain healing in former chronic substance users following mindfulness meditation programs demonstrates addition-al support for including these protocols within a treatment or recovery regimen. (Garland et al, 2013)

Over time, drug use causes atrophy in certain parts of the brain. Mindfulness meditations are mental training programs for exercising, strengthening, and remediating these brain networks. Modern science has only just begun to understand the many ways that mindfulness training addresses the connections between addiction, thoughts, and emotions. (Garland, 2013, 2016)

BENEFITS

• Results from controlled trials demonstrate significant therapeutic effects among individuals with substance-use disorders, including opiate dependence (Garland et al, 2016; Khusid et al, 2018)
• Individuals completing treatment who receive mindfulness meditation training report less drug-use than those who receive traditional relapse-prevention or 12-step meetings, at 1-year follow-up (Bowen et al, 2009, 2014; Partnership, 2014; Rettner, 2014) One study reported rates averaging 5 times lower than participants in the ‘treatment as usual’ group (Witkiewitz et at, 2013)
• Integrating mindfulness with cognitive-behavioral approaches demonstrates greater remission rates than both cognitive-behavioral (alone) and treatment-as-usual control groups. (Enkema, 2016)
• Combined with cognitive-behavioral therapy, mindfulness shows a 44–50% reduction in relapse rates for those w/ chronic depression in both initial and subsequent studies (Brewer, 2010; Witkiewitz et al, 2010)
• Significantly lower rates of depression, anxiety, and craving reported in those who received MBRP as compared to those in ‘treatment as usual’ (Bowen et al, 2009; Zemestani and Ottaviani, 2016)
• Studies reveal significant effects of mindfulness treatments in reducing the frequency and severity of substance misuse, intensity of craving, and severity of stress. (Bowen et al, 2009; Enkema, 2016; Grant et al, 2017; Khusid and Vythilingam, 2018; Li et al, 2017; Witkiewitz et al, 2005, 2013)
• Those reporting depression, negative emotion, poor self-concept did not experience typical craving patterns or subsequent relapse following mindfulness meditation (Garland, 2013; Witkiewitz, 2013)
• Incarcerated, substance-abusing individuals who were taught mindfulness meditation revealed significant reduction in substance use three months following their release, as well as reductions in anxiety and depression (Brewer, 2010)
• More successful than relaxation therapy at decreasing symptoms of stress, including blood pressure, heart rate, and muscle tension (Garland et al, 2013)
• Veterans in recovery from SUDs reported less health-related problems and improved quality of life following mindfulness meditation training (Khusid and Vythilingam, 2018)
• After 8 weeks of MBRP a sample of opioid-misusing chronic-pain patients were able to significantly reduce their attention to pain-related cues which precipitated opioid use (Garland et al, 2013)
• Individuals practicing mindfulness meditation were able to revitalize brain reward centers, enhance positive emotion, and ‘relearn’ ways to experience joy and pleasure in simple daily activities and encounters (Garland et al, 2013, 2016)
• After two months of mindfulness training, participants improved their sense of self, as well as empathy for others (DualDiagnosis.org, 2018)
• Individuals are able to permanently extinguish triggers more effectively than avoidance (Brewer, 2011; Garland et al, 2016; Grant, 2017; Thompson, 2014)
• Brain imaging shows that meditation may reverse, repair, or compensate for neurological damage caused by addiction (Bowen et al, 2013; Garland et al, 2016) –it has been found to increase gray matter in prefrontal cortex and insula, and hypothesized to compensate for addiction-induced gray matter loss (Khusid and Vythilingam, 2016)

RISK

• There are no risks associated with Mindfulness or Meditation.

Hypnotherapy has been helping patients overcome substance dependence from alcohol, nicotine, and drug use for years with high success. It works on the premise that the subconscious mind has the power to stop addictive urges and cravings, and that changing subconscious thought patterns changes behaviors. The neuroplasticity of the brain allows hypnosis to create new neural connections. Hypnosis can actually rewire the brain, so that the response of the subconscious mind to the sight, smell or thought of a problematic substance triggers an entirely new feeling.

More importantly, hypnotherapy utilizes techniques that change triggers in the brain to stop self-sabotage, release trauma, and redirect the neural networks related to other negative thought patterns. A hypnotherapist will typically work on a client’s core issues, such as memories that make the person feel weak and fearful. Many chronic substance users have a deep and powerful memory bank of failure, fears, and hopelessness, and practitioners believe that it is these negative thought patterns that lead to relapse. Changing the way the brain reacts to these memories actually stops the cravings and the desire for drugs or alcohol.

Once the old beliefs and triggers are released, the therapist can then work to create a new belief and a new healthy identity. Individuals are taught to replace their negative thoughts about themselves and their perceived ‘powerlessness’ over addiction with positive beliefs about being healthy, powerful, and in control. By envisioning oneself as strong and powerful, one changes the way their brain reacts to drug memories and triggers. Then, when the patient is exposed to any of their normal triggers, their brain’s automatic response is derailed and new responses, encoded during these brain retraining sessions, take over –so that what once caused cravings and relapse, now actually reinforces the commitment not to pursue or engage in problem substances. Once they cease to be controlled by a substance, they need to identify with being something
other than an ‘addict in recovery’ for the rest of their life. When they give up this self-defeating label, they begin to live their life in a way that provides them with the rewards and accomplishments that make them feel ‘recovered’, further reinforcing the idea that they are NO LONGER an ‘addict’. Hypnotherapy changes a person’s deepest beliefs about who they are, and this is where hypnosis makes some deep and lasting changes.

BENEFITS

• Reduces illicit drug use among patients using opioid replacement therapies (Manganiello, 1984) by as much as 100% at 6-month follow-up, and nearly 80% at 2-year follow-up (Kaminsky et al, 2008)
• Assists patients tapering off opioid replacement therapies demonstrating a 94% success rate after six months abstinent (Manganiello, 1984)
• Assists patients in avoiding relapse by 77% (Potter, 2004)
• Contributes to higher levels of self-esteem and serenity, and lower levels of anger and impulsivity among chronic drug/alcohol users enrolled in treatment programs (Pekala et al, 2004), and reduces anxiety –a post-acute withdrawal symptom (Melis, 1991)

RISKS

• There are no risks associated with hypnotherapy