Nine Candid Thoughts About Substance Abuse Treatment and the 12 Steps
I am 24 years sober today, and of those years, 20 of them have been working in the substance abuse/behavioral health field. I’ve gathered a random sampling of thoughts on treatment and AA. If you agree with all of them, then I have either bored or failed you. Check them out:
1. Cliche to say, but treatment works. It saves lives and ripples to save families. You will hear all sorts of stats, sometimes as low as only 1 in 10 who participate in substance abuse treatment will stay sober for a whole year after discharge, but there are other stats that state almost 50% of those in treatment at any given time will be sober ten years later. It just may take a few attempts for it to stick into long lasting recovery.
Also, ‘treatment’ is such a broad term describing such different levels of interventions. The question is what type of treatment works best, and when. I’ve always felt that inpatient or residential treatment squeezes folks a bit harder to get to some necessary truths and insight. (For when you squeeze an Orange, you get Orange Juice, because that's what’s inside. Well, when you squeeze an addict, you get what’s inside as well.) Inpatient treatment can do this squeezing best in a safe situation and stop a relapse in the early days so that long term recovery can take roots. Yet less restrictive modalities such as day treatment programs and intensive outpatient give the therapist and client real life scenarios to process and do not offer the fantasy scenario of living 24 hours in a therapeutic environment. In general, the world out there wants you go get high, so go fight it, (with friends at your side) and come back to report.
2. Treatment doesn't work, for some folks, at least in a traditional 12-step model. I believe that substance abuse treatment has cast too wide a net, and that there are many patients in substance abuse specific treatment who are actually primarily personality disorder or other diagnoses that are ill-served by giving them traditional CD treatment. For these folks, using drugs or drinking is just one of many symptoms that often include other anti-social traits.
I am not talking about the bipolar or depression diagnosed client where the two disorders feed off of each other and make both set of symptoms worse. I am referring to some axis 2 personality disorders or affective disorders. We throw them into the mix and treat them the same, and it’s a set up for failure for both client and clinician. Asking a client with narcissistic personality disorder to get humble and ask for help is cruel and unusual punishment for all involved. An untreated borderline personality diagnosed patient with acute symptoms sits at a first step table and nobody gains. What happens is, many of the social arenas provided in treatment, including groups and 12 step support meetings, are actually just another stage for the narcissist or anti-social personality disorder member to practice their pathology. This is especially prevalent as cluster B personality disorder traits, who end up in the criminal justice system, are mandated chemical dependency treatment.
3. There are too many recovering addicts treating other addicts. Okay, maybe I contributed to the problem, but I find that when folks become ‘experts’ and well-versed at AA or NA, they tend to expect others to work a program or get sober exactly as they did. These are the folks who do way too much self-disclosure, and every moment is an aa/na meeting, and they have a slogan for every situation. Treatment center staff who gain a masters degree only as an excuse to further their own personal agenda, which is pushing their own way of treatment onto others. Ironically, these therapists are often the most popular and heralded at treatment centers, but maybe not the most effective. They often have a fervent desire to spread their recovery gains to others, and you can’t deny the enthusiasm, but many times it could stay at the tables rather than inside facilities.
4. AA and NA itself is not treatment
Let me explain. The focus of treatment needs to be on clinical issues such as negative, self-destructive thoughts, inability to manage emotions or self-soothe without substances. (just as an example, for there are tons others.) Treatment is facing cognitive distortions, behavioral patterns, and cognitive reframing to find hope amidst despair, as well as identifying concrete and tangible behavioral changes and skills. Treatment should not be a boiler plate of writing out ones first step, listing 3 examples of powerlessness, writing an autobiography, getting a sponsor, identifying a higher power, watching a Father Martin video, etc... These things are essential, I believe, but they are a supplemental. Too often, the steps are seen as the only form of therapy.
5. AA and NA saves lives and understands addicts better than any Counseling theory.
Counseling theories can be applied to character defects as a path to change, but the words in AA/NA are so incredibly powerful once the addict starts to feel their meaning. The concept of powerlessness, once I understood it, saved my life and was the most “Ah-ha” moment I have ever had, and the steps went on from there. In this case, things are not true because they are in the big book, the big book writes about them because they are true. When the promises, as described in the big book, start to come true, sometimes quickly, sometimes slowly, it’s an amazing and miraculous process. So many of the other self-help addiction modalities I find are just slightly altered versions of the 12 steps, but packaged differently. Recovery saves lives, and the concepts of the 12 steps lead to recovery.
6. Leave the Lord’s Prayer at Home
There is a reason the 12 steps has certain words italicized or underlined. God as we understood him, twice, in case you weren’t looking the first time. Having this phrase presented in such a way is like banging the newcomer on the head saying, “yeah, it says God, but it’s GOD as You understand him, so don’t leave, please, don’t! we are open to your interpretation.” Sounds genius. and so very empathic to the spiritual maladies of an addict in despair.
But then, should you decide to sit through the meeting, we hit you with the Christian theme song at the end.
This should change. I find the lord’s prayer at a meeting an incredibly powerful moment, but for me it is less about the power of the words than one final connection to the group. A silent way to ponder what we felt before we go off into that good night. We could be saying ‘take me out to the ballgame’ holding hands, head bowed solemnly, and it wouldn’t lose its purpose. I was raised Catholic, but have come to identify with a sort of metaphysical Christianity, and feel the story of Christ and harrowing hell and ascending to heaven, of suffering and redemption, to be a powerful message of faith, but that need not be the final money shot of AA meetings.
The 12 steps are not about staying sober. Look at the steps, and the sole reason for working them, the result, is a spiritual awakening. And once you have a spiritual awakening, (all the while doing the clinical work) you will not need to use substances. Let this happen in an environment that is not explicitly Christian. When God comes to the hungry, he comes in the form of food.
7. Substances are different, yet addicts are the same.
Clinicians can really hate when the alcoholics pretend they’re better than the cocaine addicts who are definitely not as hip as the opiate addicts carrying a copy of “Heroin Diaries” with them, while the prescription pill gobbling client feels they are better than everyone since a doctor prescribed their fix. These kind of divisions are always discouraged and represent a form of minimizing. Clients are asked to relate, not compare.
But I do believe we should stop pretending all addiction is the same. Certain substances are simply more powerful. A small dot of cocaine or crystal meth, or a small rock of crack simply have a different effect on the mind. In this case, I do believe you have had to have used them to understand, and this is an example of the power of a clinician being in recovery. (I’m primarily an alcoholic, but have used multiple substances, and never want to be in the same room as a line of cocaine or crystal meth, but am often around alcohol.) That said, once a heroin addict, alcoholic, or cocaine addict are in the middle of their cravings and in their seeking mode, the inertia, the cravings, and the obsession to use is all the same. Compulsions to use are equal.
8. Addicts will not follow suggestions. Never at one hundred percent, or even 90 percent, or even 75 percent, nor should they. This drives therapists crazy when a patient consistently ignores suggestions to change (as in, if you are jumping off a plane, I suggest you use a parachute.) Making choices is essential, including the wrong ones, and there is more to learn by failing than fear of failing.
100 percent of us clinicians can agree with their dentists recommendation to floss their teeth regularly, but maybe 30% do. (Because when you are pointing three fingers at me, you have one finger pointing back at yourself and the broccoli stuck in your teeth)
9. Physician heal thyself.
Clinicians, MSW's, Psychiatrists, and other caregivers experience incredible stress, however, it is the healthy few who use their skills to address these issues. This means therapy for the therapist. There is nothing more relaxing and helpful than going to therapy oneself when one is a therapist. It’s a masseuse getting a massage, where you know the therapeutic power of the process. Of course, it can also be hard emotional, mental and spiritual work that you need to do in order to stay healthy. Monkey’s off your back, the circus is still in town, as it’s been said. Recovery, like truth, is stranger than fiction or addiction. And stupid choices, despair, existential crisis, happen to everyone to some degree, and if you’re not open to visiting the place you feel provides the change agent, then how can you expect it of those you serve. The adage is it is the most mentally healthy and the most mentally troubled who are in counseling. I’ve spent time in both camps.
That's it for now. There are of course tons more thoughts and elaborations I can do on each of these, but I’ll hold you hostage no longer. Thanks for listening. Time for a moment of silence followed by the serenity prayer.
About the author:
Mark Matthews has a Masters in Counseling and has worked in addiction and mental health treatment for nearly 20 years. He is a graduate of the University of Michigan and has been in recovery from his own addiction since 1992. An avid writer and runner, many of his novels feature drug addiction including MILK-BLOOD which has been a bestselling chemical dependency novel on Amazon since its release. Matthews has run over 13 marathons including Boston, New York, and Chicago and has written about the power of running as a natural high in Chasing the Dragon.