12-Step Programs versus Evidence-Based Addiction Treatments

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.

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12-Step Programs Versus Evidence-Based Addiction Treatments by Alisa Huskey

Alcoholics Anonymous groups are one of the oldest and most popular methods of rehabilitation for addiction problems. Since the 1930s, when AA was formed, a variety of addictions have stimulated the formulation of different types of anonymous groups (e.g., Narcotics Anonymous, Gamblers Anonymous). The same 12-step principles govern each group, without many adjustments since they were codified in the 1930s. The main tenets of 12-step programs involve abstinence (complete sobriety), surrender to a higher power, admittance of wrong, and a willingness to change. The importance of establishing a spiritual connection with a higher power is stressed throughout the 12-steps. Step number eleven posits that:

[We] 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.

And yes, the “H” in Him and His is really capitalized. There is reported leeway as to which higher power with which one wishes to connect (although how much this actually occurs is questionable). However, there is little to no room for individuals without any religious or spiritual conviction in these recovery groups.

Weekly meetings typically involve personal confessions of “faults and failures” (relapses), 12-step review, and discussion. Step number five states that “[we] admitted to God, to ourselves, and to another human being the exact nature of our wrongs.” Every member typically has a sponsor that provides moral support. Sponsors are members that have been involved in the program longer than their mentees. According to individuals having gone through the program, having a sponsor is the most beneficial aspects of AA. The main weakness of 12-step programs, from a therapeutic perspective, is the unavoidable religious overtones. While this could be beneficial for some, it could simultaneously prove to be a detriment to a non-religious person seeking support during recovery. These programs also seem to breed an environment of guilt and shame, viewing addiction as a character flaw rather than a physiological or psychological disorder and supporting a very “all or none” view of treatment outcomes (abstinence is the only possible good outcome). And perhaps the most damning flaw of these programs is that they do not seem to work based on all available data.

But what’s the alternative? How about some methods to treatment that are actually based in evidence and reason?

For example, Marlatt’s model of relapse prevention promotes a more healthy view of addiction and facilitates client autonomy by providing psychoeducation on the recovery process. This model purports that client coping strategies and confidence, outcome-expectancies, and the initial substance effects determine response to high risk situations when relapse is probable. The abstinence violation effect is the client’s propensity to feel shame and guilt resulting from a relapse, regardless of it severity. A relapse typically increases the probability of a more severe relapse and a lack of confidence to continue with treatment. To prevent this from turning into a downward spiral of relapse, clients are taught understand abstinence as more of a learning curve; and thus, to expect relapse to occur, but less often with time. If relapse is expected it will not be considered a total failure, so then motivation to continue will be easier to find. Additionally, according to this model of relapse prevention, environmental factors are greater predictors of relapse, as opposed to personal will-power (which can also translate to personal flaws for some individuals).

Cognitive-behavioral therapy (CBT) is another therapeutic approach for treating substance abuse. CBT largely disregards the genetic/biological origins of addictive behavior, but rather assumes that behavior is learned through processes such as classical and operant conditioning, for example. The physiological aspects are perceived as the static platform on which environmental factors build, leading to individualized approaches to learning behaviors. An example of classical conditioning and the development of alcoholism might involve the following. Ted, a young twenty-something recently broke up with his girlfriend. The following day, Ted decides to stop by the bar after work to have a few drinks. A few drinks in (alcohol = conditioned stimulus; CS), Ted becomes fast friends with the bartender and a couple regulars sitting next to him (warm fuzzy feelings of friendship = unconditioned stimulus; US). Ted began to make this a common occurrence and soon became a regular himself (conditioned response; CR). Within few years, drinking became a problem for him. While social interaction, such as that experienced at the bar, may have by itself elicited those warm fuzzy feelings of friendship, Ted associates those feelings (originally the US changed to the CS) with the alcohol.

Because learning is believed to be the basis for behavior and thought-patterns, teaching new patterns of behavior (and thinking) is basis for the CBT approach (i.e., re-learning or un-learning). Some CB theories promote changing client environment, while others promote changing client reactions to the environment. Regardless of these small differences, the focus remains on the individual-environment interaction as the basis of CB theory and treatment. Another fundamental aspect involves the assumption that internal functions (thoughts and beliefs) impact external behaviors and vice versa. Thus, changing the patterns of one influences the other. Therapeutic alliance, often composed of motivational interviewing (see below) and contingency management, are also complementary to the cognitive and behavioral restructuring components of this approach.

Motivational Interviewing (MI) involves Socratic exploration which allows the individual to explore some of their own destructive and impairing patterns. Consistent reinforcement of client behavior, particularly with treatment of substance abuse, promotes awareness and monitoring of behavior. The mechanisms of knowledge, motivation, and resistance recognition are used to facilitate change. Formulaically, the assumption is that knowledge multiplied by motivation, divided by resistance will result in variable levels of change. The theoretical basis of MI lies within aspects of humanistic psychology, cognitive-dissonance theory, and self-perception theory. Instead of providing direct advice to the client, therapists employ “motivational” questioning or suggestions that allow the client to explore their own attitudes towards changing as well as perceived resistance to change. Clients are encouraged to engage in “change talk” (positive speech/thoughts about change) and avoid “sustain talk” (speech/thoughts about maintaining unhealthy cognitive and behavioral patterns). Change talk is based upon self-perception theory, which purports that people develop attitudes about their own behavior similar to interpretation of others’ behavior – by observing behaviors and then attributing attitudes that motivated them. Thus, change-related speech will contribute to change in behavior. This also builds upon cognitive-dissonance theory, in that people often feel ambivalent about changing their cognitive or behavioral patterns, even when they are self-destructive, like substance abuse. An increasing amount of literature has emerged over the last decade examining the therapeutic effects of MI. Meta-analyses indicate that MI is frequently equally as effective as other evidence-based treatments (e.g., CBT) for treating substance use problems.

Understanding the complexity of a client’s individual environment and thinking patterns is reflected in the emphasis placed upon the rigorous assessment involved in CBT and MI. For example, clients choose to seek treatment at different stages in the development of their presenting problems. Identifying client’s stage of change has been shown to be an effective technique for tailoring treatment to individual needs. Norcross and colleagues identified five stages: precontemplation, contemplation, preparation, action, and maintenance. Assessing the stage of change of an individual is particularly beneficial for clients struggling with substance and abuse problems. Stage of change can predict the outcome and effectiveness of treatment, as it reveals client’s readiness to rehabilitate. This, it turns out, is a regular part of CBT and MI, but not in the 12-step programs.

In sum, there are treatments that work for those struggling with maladaptive substance use. These treatments, though, are not what most people tend to think of when they hear the words “addiction treatment.” Hopefully, as the healthcare system of the United States moves increasingly towards requiring evidence-bases for what we do, this will change.