Awareness Month Feature Article by “The Fix” Explores The Topic: ‘AA Is not an Evidence-Based Treatment’

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AUTHORS NOTE:

“I am in no way demeaning or saying that The 12-Step Program and model is not a form of treatment, nor that it doesn’t help people recover from drugs, gambling, or alcoholism.  But more and more articles like the one I am sharing today and hearing many people talk about needing and wanting MORE than 12-steps to reach long-term recovery and have a well-balanced path from ADDICTION.”

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So please don’t leave me nasty comments as to such. What I am exploring is a more in-depth look into having “Wellness in Recovery.” Many are now searching for ways to obtain treatment AND learn the much-needed skills and tools to begin the “inner work” needed to a well-balanced recovery without relapse or slips in the process.

Let’s face it, if we teach new addicts coming into treatment BOTH, we just may cut relapse percentages in half or more and would mean MORE NEW addicts would be getting the help they need as well.

There are many ways to go about it this.

One new exciting way I have been using and venture I am involved with is for those working in the “treatment side and facilities” and those looking for recovery “AT HOME Recovery.”  Learn more about “Wellness in Recovery” and “Oak Valley Productions Educational DVD Series.” It is a fresh approach to having a well-balanced journey, learn to begin and process the underlying issues that may have you turned to addiction, and learn to release and let it GO!

It will help guide you on how to begin your “inner work” as you learn the educational side of recovery from addiction! See all the details of this non-12 step recovery series and have  “Recover in Wellness” of mind, body, soul and Spirit!

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FEATURED ARTICLE: AA, GA, NA, Is not Evidence-Based Treatment by, Laurel Sindewald 03/16/17

“Researchers have not been able to methodologically eliminate self-selection bias or utilize adequate controls in their studies of 12-step groups and Twelve-Step Facilitation.”

When I read Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, I was surprised to see Twelve-Step Facilitation (TSF) included as an evidence-based behavioral treatment for addiction. I had just done a literature review on the efficacy of 12-step-based interventions and found the evidence insufficient to support the prescription of 12-step groups as treatment. TSF is a standardized form of therapy where professional counselors try to engage their patients in participating actively in 12-step groups, in part by emphasizing 12-step philosophy during therapy sessions.

Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment. A spiritual disease concept is not the same as a medical disease concept. Twelve-Step Facilitation treats addiction as a spiritual and biopsychosocial disease, retaining the spiritual emphasis of 12-step philosophy.

TSF was classified as a professional behavioral treatment in the Surgeon General’s Report. How can a professional, medical treatment be based on a definition of addiction as a spiritual disease? Baffled, I knew I would not be able to understand if I got stuck in bias against Twelve-Step Facilitation. I had studied the research on 12-step groups, but had only dipped my toe into the research on TSF. The Surgeon General’s Report cites hundreds of studies, and over a dozen in support of TSF. So, I did what all good scientists must do: I set aside my bias, knowing that if I want the truth, and I must assume first that I am wrong and dig deeper.

I conducted a preliminary literature review to investigate the effectiveness of TSF as a treatment, and then examined each of the sources the Surgeon General’s Report cited in support of TSF. I looked at the methodology, results, and conclusions for each. In this article, I define “evidence-based” to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. I use “12-step approaches” to refer to all 12-step-based rehab programs, TSF, and 12-step mutual help groups.

The key to understanding research on TSF is to know why the treatment was created in the first place. Researchers had documented a correlation between 12-step group attendance and abstinence, but correlation is not causation and research had been limited in several ways:

  • Studies evaluating the effectiveness of 12-step groups could not eliminate self-selection bias, which happens when group members are not randomly selected and participants opt in or select themselves, creating biased samples. The people participating in the studies had chosen to participate, and researchers could not determine whether successes observed were due to 12-step participation or qualities in the self-selected participants, such as greater motivation to enter recovery, more resources, or greater receptivity to messages of God, faith and/or acceptance. The people who chose not to participate, or who dropped out of the study, were not always accounted for. Researchers could not determine whether the correlation they observed was due to the treatment or to the characteristics of the people participating.
  • Twelve-step groups have no standardized methods or conditions. Leaders of the groups are often laypeople in recovery from addiction themselves. The quality of social support in the group depends on the people who are participating. The literature is interpreted by the members, who create their own cultures around the interpretation. Twelve-step cultures also pass around other information and advice, which may or may not permeate every group. Each sponsor is a different layperson in recovery from addiction, with different character traits. Researchers could not control for all of these variables all of the time.
  • Researchers struggled to maintain rigorous control groups throughout studies. At a minimum, to determine whether 12-step groups have an effect, researchers needed a no-treatment control group for each study. Ethically and logistically, they could not prevent people in the control groups from receiving treatment or from attending 12-step groups.

 

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Twelve-Step Facilitation was developed by researchers working on Project MATCH, a well-known and extensive study funded by the National Institutes of Health. Project MATCH compared TSF to Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT), seeking to establish what patient characteristics corresponded with the best results for each treatment. The study found there “was little difference in outcomes by type of treatment” based on the primary outcome measures of percent days abstinent and drinks per drinking day.

By standardizing methodology for TSF, Project MATCH made some headway on strengthening the quality of evidence, but they did not find a way around self-selection bias and they did not have a control group. Many patients, however, did drop out of the assigned treatments early on in the study. Two researchers later examined the outcomes of the zero-treatment dropout group, and found that “two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero-treatment group.”

This means that the people in Project MATCH’s treatment groups did not have significantly better abstinence outcomes than the people who dropped out of the study. Importantly, we do not know whether the dropout group sought treatment on their own, and it seems probable that they did. Based on their analysis, none of the interventions in Project MATCH seem to be effective, but without an actual control group, the results are equivocal regardless.

Some researchers have sought to re-analyze other parts of the Project MATCH data, but their findings, while supportive of TSF, are subject to the same methodological limitations of the parent study. Many other studies cited by the Surgeon General’s Report seem to support TSF as effective for improving abstinence outcomes and/or for relatively increasing 12-step participation compared to treatment as usual (TAU), but none of these studies had control groups. The Surgeon General’s Report cited one source in support of TSF that was actually an article reviewing information about 12-step programs to educate social workers, not an experimental study. The Report also cited a study in support of TSF that examined two active referral interventions, 12-step peer intervention (PI) and doctor intervention (DI), compared to no intervention (NI). The study found that while the active referral interventions significantly increased participation in 12-step groups compared to no intervention, “abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI]).”

This study was the only one cited in the Surgeon General’s Report in support of TSF that approximates a control group, and it does not actually support the efficacy of TSF in increasing abstinence outcomes. The NI pseudo-control group still received a list of 12-step group meeting times and locations, but was not encouraged to attend. The PI group attended meetings twice as much as the NI group, and yet the researchers found no significant difference in abstinence outcomes. The DI group, essentially TSF, was less effective than the PI group at increasing attendance, and again, did not significantly improve abstinence.

My own literature review turned up articles the Surgeon General’s Report did not reference, both in support of TSF and not supporting TSF, but none of the studies I found had control groups either. Results of my literature review, including my assessment of the Surgeon General’s report sources, were therefore as ambivalent as the 2006 Cochrane Review, a systematic meta-study of all 12-step-based programs that found “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.

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In medical science, if a treatment is ineffective or faces prohibitive methodological challenges, the treatment is either revised or abandoned. Twelve-step philosophy prohibits either approach. Twelve-step literature is comparable to the Bible for Christians or the Qur’an for Muslims; if the literature is removed, the identity of the group goes with it. The same basic text has been used for AA since the publication of its “Big Book,” Alcoholics Anonymous, in 1939. Twelve-step literature also explicitly states that “Those who do not recover are people who cannot or will not completely give themselves 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. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.” Twelve-step philosophy, by taking this position, is asserting that its methods can never be wrong. If the 12 Steps do not work for people, 12-step philosophy explicitly states it is their fault, and that the fault is inborn and irreversible. The 12 Steps and attendant literature, however, are not modified.

Research does support the concept that changing “people, places, and things” and finding a network of people with a culture of abstinence can improve chances of recovery. However, mutual help groups other than 12-step groups do exist that may provide the social support needed by people in recovery. People who are not religious may be able to make 12-step groups work for them as social support if they have no other choices, but other options will most often be available.

A study in 2001 by Humphreys and Moos found that TSF may reduce health care costs for people in recovery by emphasizing reliance on free 12-step groups, as opposed to cognitive behavioral therapy. Yet their conclusions that the study indicates people should be diverted from CBT to TSF because it is ultimately cheaper amounts to advocating malpractice. TSF itself is not free and is not decisively supported by evidence; twelve-step groups, while free, are not evidence-based treatment, and other available mutual help groups are equally free options for social support. Even if TSF were demonstrably effective at promoting abstinence for some people, 12-step philosophy is heavily spiritual (specifically Christian-based) so it would be unethical to recommend TSF simply because it might save money.

After exhaustive research, I assert with confidence that 12-step approaches are not evidence-based treatments. They may be strong recovery support for people to choose in addition to a medical treatment plan, but 12-step approaches—including TSF—are not established as evidence-based for treating addiction.

Due to the methodological limitations identified in this article, I question continuing to spend thousands of dollars, hundreds of hours, and invaluable expertise on researching a spiritually-based treatment for addiction that cannot be proven to be effective for most people most of the time compared to “spontaneous,” or natural, remission rates. It is time to relegate 12-step approaches to the realm of recovery support services (RSS, as defined in the Surgeon General’s Report), and allocate our research resources to promising treatments that can be studied rigorously and without such crippling methodological limitations.

** Laurel Sindewald is a writer and researcher for Handshake Media, IncorporatedAnne Giles contributed to this report. ** 

 

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Recovery and The Holidays. A Guest Article That Helps.

Merry Christmas Recovery Friends,



I have another wonderful guest article I have come across over on The Fix that really is helpful for all of us who live life in recovery. We can never be ready enough for when holiday stress comes our way in recovery. So here are some tips to keep you snug in early or long-term recovery!

Home for the Holidays? Top 10 Strategies for Staying Sane & Sober

By John Lavitt 12/22/15

“These strategies have worked in practice for countless alcoholics and addicts in long-term recovery.”

“Have you ever noticed how Hollywood has made a cottage industry out of Christmas disaster comedies where going home for the holidays becomes something of a living nightmare? From I’ll Be Home for Christmas(1998) and The Family Stone (2005) to This Christmas (2007) and Home for the Holidays(1995), this subgenre has come to symbolize the challenges that going home for the holidays represents for all of us. Such a challenge, however, becomes even more difficult when you are in recovery from alcoholism and addiction, particularly for the newly sober.”
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“By creating a heightened awareness of your old triggers in advance, you will not be surprised by them when they pop up over the holidays.”
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After all, how are you supposed to deal with all of those antiquated family triggers that bring out the very worst in you? What are you supposed to do when that annoying uncle keeps offering you his special eggnog with that extra special kick? How do you navigate when you feel cornered and overwhelmed?

The goal of this impromptu Home for the Holidays How-To Guide is to provide you with strategies that will help keep you both sober and sane over the Christmas break. These strategies have worked in practice for countless alcoholics and addicts in long-term recovery. In fact, many of them have worked for me, saving my ass when the going got tough because the inside of my head was getting ugly.


1) Set up an out-of-town meeting schedule in advance.

We are so lucky to live in the 21st century where so much can be accomplished over the Internet in advance! If you are traveling, use the websites of the 12-step programs to find meetings in advance. After figuring out your basic holiday obligations and commitments with your family, set-up a meeting schedule that works for both you and your family. At the very least, know the daily meetings you can attend in your area and try to figure out what meeting you are going to go to first.

If you haven’t done this in the past, you are going to be impressed. Across the world, 12-step members are so open and giving to out-of-towners, particularly over the holidays. You will very likely find the temporary emotional support, positive feedback and empathetic commiseration that you will need to help you stay sober and sane over the holiday season.

2) A heightened awareness of your old triggers is essential.

Before you go home for the holidays, think about the past and go over your old triggers with your sponsor or a friend. As Peter Griffin is fond of saying on Family Guy, talk about what really grinds your gears when you are with your family. By creating a heightened awareness of your old triggers in advance, you will not be surprised by them when they pop up over the holidays.

When they do pop up, take advantage of your heightened awareness to mollify them and take away their power. Please remember that triggers have no power on their own; they only have what you choose to endow them with. I have found that talking to them works well, although it’s best not to do in front of other people. Rather, when I’m by myself, or in the bathroom, or out for a quick walk, I recognize their presence and say something like this: “Oh, it’s you again. Welcome back. Considering that I’m home, I’m not surprised to see you. After all, my family has always gotten under my skin in that particular manner. This time around, however, I am choosing not to be bothered by you. Maybe next time, maybe even tomorrow, but just for today I am going to let it go.”

I know it sounds silly to talk to your triggers in such a manner, but it also can prove to be highly effective. Such a conversation frees you from the burden of having those triggers fester like an open wound in your psyche. At the same time, by talking to the triggers, you place them outside of yourself. Feelings are not facts, and triggers are not necessarily part of who you are at the very core of your being. Rather, they are a situation you are experiencing, and a heightened awareness of that situation, of those triggers, can free you from their control.

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3) Be an amazing guest by being of service to your family. 

I remember going home for the holidays several years back and calling up my sponsor because I was feeling very resentful. My whole family lives in Park City, Utah, and I live in Los Angeles. When I got there, we went out to dinner as a family and all of the conversations at the table were about Park City and the ski team and the local mayor and so on and so forth. Nobody asked me anything about my life in the City of Angels. It really pissed me off. I was triggered so I reached out and called my sponsor.

As I was grumbling about the lousy dinner, my sponsor speculated, “I’m sure they planned this in advance because everything really is all about you. Right now, you’re doing a great job thinking all about yourself all the time. How’s that working for you?” Feeling picked on again, I answered, “Not that well.” My sponsor chuckled, “Then how about trying something different? How about trying to be of service to your family and be an amazing guest in your parents’ home?”

Although resistant at first, I was amazed by how well this approach worked in practice. When help was needed, I went shopping for last-minute groceries for my mom. Every day, I offered to do the dishes and walk the dogs; I took advantage of any opportunity to be of service. My parents were somewhat amazed by this change of stripes. They started asking me about my life back in Los Angeles, wondering what had happened to affect their son in such a positive fashion. In other words, by being of service, I actually got what I initially wanted and so much more. I got out of my head and into action. Most importantly, I felt good about myself. Such a strategy seems to work.

4) The negative reaction happening in your head is not reality.

As alcoholics and addicts, please remember at all times when home for the holidays that we have a disease of perception. Personally, I tend not to see situations correctly at first glance, and I tend to take things personally, letting my emotions jump in and take control of a situation. My old sponsor used to tell me that this is the difference between a reaction and a response. My initial reaction is based on what’s happening in my head, and it’s not reality. Rather than giving in to this knee-jerk reaction, I can use the tool of the pause.

The pause allows you to take a step back from your emotions. My old sponsor always recommended that I take three breaths. In any situation, unless a maniac is chasing you with a knife, you should have time to take three breaths. If you don’t feel you have time to take three breaths, then something is most likely off with you and not with the situation. By taking three breaths, the pause comes into effect.

Suddenly, it becomes apparent that my father wasn’t trying to put me down, but he actually was making joke. Maybe a bad joke, but definitely a joke. My sister wasn’t insulting my career choice, but just reflecting on her own frustrations with her work. The pause helps me to realize that my first reaction is not reality. Instead of a knee-jerk reaction, I am given the grace of making a balanced response that comes from a place of positivity. Such a shift can be the difference between a lousy and a wonderful evening while home for the holidays.

5) Use the phone, FaceTime, Skype and the Internet to keep in touch.

When you are away from your support network, it’s very important to stay in touch. Please use the phone, FaceTime, Skype, the Internet, or whatever works for you to keep in touch. If the pause described above isn’t working, take a step outside or go to the bathroom in order to call a trusted friend or your sponsor. Let them know what is happening and externalize your fears, resentments, worries and discomfort. The very act of externalization often is enough to shed light on a dark corner, giving you the ability to move on from a perceived difficulty. By keeping in touch with your support network, you keep yourself safe. You use the tools in your recovery tool belt to make most bad situations better.

6) Choose what non-alcoholic drinks you’ll have ahead of time. 

When going home for the holidays, I always know that I’ll have to accompany my family to a few holiday parties where a lot of people will be drinking. I prepare for these parties by knowing what non-alcoholic drinks I am going to order ahead of time. If you don’t feel like having a Coke, I have found that soda water with a lime or mixed with cranberry juice can be an effective drink to avoid any unwanted questions. Such a drink looks like a mixed cocktail, but isn’t. If such a drink is not a trigger for you, it can do the job. At the same time, just a bottle of water or a glass of orange juice works great. As long as you know what you will be ordering before you arrive and you give yourself a few options to deal with availability, you will not stumble into an uncomfortable situation.

7) Free yourself from any pressure to justify or explain your sobriety.

Please do not be afraid of that relative who will pressure you to have just one glass of champagne or a shot of their favorite whiskey. You don’t have to explain to them why you don’t drink. And you definitely don’t have to do this with a stranger at a party or out on the town with friends. Instead, you need to free yourself from any pressure to justify or explain your sobriety.

Rather than telling my story or sharing like I was at a 12-step meeting, my sponsor recommends that I tell people that alcohol simply doesn’t agree with me. If you tell someone that drinking any alcohol at all makes you feel sick, very few people will ever push the subject beyond that point. After all, if you have an allergy to alcohol, as it says in the Big Book, then you aren’t making anything up. You are simply letting them know that drinking does not work for you, but you are happy that they are enjoying themselves. In such encounters, keep to the positive side of the road, and they will pass quickly.

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8) Don’t get trapped; try to have a way out waiting in the wings.

Despite using all of the above tools, you still might find yourself in a sticky situation where you feel the necessity to leave. My sponsor reminds me not to get trapped anywhere while on vacation, even in my family’s home. He believes it’s essential to have a way out like a rental car or the phone number of the local taxi company. When connected to the local meeting schedules that you looked up before leaving, such transportation can help you out of a sticky situation and into a comfortable seat in a meeting.

Even when we apply all the tools that we have learned in our recovery, things can often get overwhelming when it comes to family. In most cases, this hopefully won’t happen to you, but it can. I promise it will pass if you are able to take a breather. If you can’t get to a meeting, go for a walk. When I am on vacation, I love taking my parents’ dogs for a walk because it allows me some time on my own. Although a rental car tends to be the best answer, public transportation works well in most big cities. If you can’t afford a rental car and don’t have access to public transportation, try to develop other strategies. Saving up a small sum in advance for emergency taxi rides can be useful.

9) Embrace physical activity, sweating and the adrenaline rush.

If you are going home to a white Christmas, embrace the fun of winter sports. Go skiing, sledding, skating or snowshoeing. If you have kids and relatives or even if you don’t have them, build a snowman. The cold air of winter is so refreshing and does wonders for the soul.

If you have any lingering old resentments against certain family members (don’t we all?), a playful snowball fight can be a cathartic release as long as it remains playful. No slush and no ice needed: Always embrace the Golden Rule when it comes to snowball fights and any casual roughhousing. Never do to another family member what you wouldn’t want done to yourself or your child.

If you are going home to Palm Springs, or the like, for the holidays, the above is a bit beside the point. Instead of celebrating a winter wonderland, go for a swim or a jog. Ask your family if you can go to their local gym, even setting up a temporary membership in advance. My father is always thrilled when I go to the gym with him as opposed to staying home and watching football. Finally, a hike in the hills with your favorite family pooch or your partner allows you to both get away and work up an appetite.

Physical activity is essential. Sweating and the old adrenaline rush are great releases for addicts and alcoholics. Now I am probably dating myself here, but remember that Olivia Newton John hit song “Physical”  from 1981? The lyrics of that song really apply in this case: “Let’s get physical, physical/ I wanna get physical/ Let’s get into physical/ Let me hear your body talk, your body talk/ Let me hear your body talk.” Yes, innocent Olivia Newton John—famous for playing Sandy in Grease—was singing about sex, but letting your body talk by working out and sweating over the holidays makes a lot of sense.

10) Revel in the corny and wonderful spirit of the season.

When it comes to the Christmas season, I love watching holiday specials to get in the mood. Frank Capra’s It’s A Wonderful Life or the Charlie Brown Christmas Special are staples that make me smile. In the past, I often identified with George Bailey and his hardships or Charlie Brown’s droopy little tree that nobody seems to like at first. It always was a relief to know that a happy ending was right around the corner. Modern Christmas movies like National Lampoon’s Christmas Vacation, The Santa Clause, and Elf can help take the edge off of a family gathering by making you laugh at the inherent goofiness of it all.

Christmas cartoons and specials make me smile. Dr. SeussHow the Grinch Stole Christmas remains a perennial favorite. I really do love the Grinch and identify a bit with him as well. When every year his heart grows three sizes on that Christmas day, I feel like my heart grows as well. Finally, Rudolph the Red-Nosed Reindeer, Frosty the Snowman and Santa Claus Is Comin’ To Town are classics that shuttle me straight back to the magic of childhood. Any one of these shows can help you revel in the corny and wonderful spirit of the holiday season.

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If your family celebrates the Christmas season, decorating the tree and hanging stockings can bring out the hidden kid in you when you head home for the holidays. Although I am Jewish by heritage, my sisters and I would often stay up late and go to Midnight Mass on Christmas Eve, enjoying the ritual and being with a bunch of happy people in a group setting. We also enjoyed and still enjoy driving around our town and checking out the best Christmas decorations and lights. As kids growing up in New York City, we particularly loved going to Rockefeller Center and checking out the famous Christmas tree lights. Such simple excursions can create intimacy and bring out the best in everyone.

If you celebrate another tradition like Chanukah or Kwanza, lighting the candles on a Menorah or taking part in the ancestral role call can connect you to your past and the meaning of the holiday season. If you and your family are big Seinfeld fans, you can celebrate feats of strength and dance around the Festivus pole as an alternative to the commercialism of the season. Whatever works for you is what is important.
Find the corny and wonderful spirit of this magical season that lights up the eyes of children around the country. By accessing this spirit of the season, you can make a trip home for the holidays into a joyous adventure as opposed to sinking into a negative morass. Yes, it can be a challenge at times, but I hope this list of top 10 strategies not only helps to keep you sober and sane, but also helps to make this holiday season a lovely experience for you and your family. . . .

Wishing you and yours a very Merry  Christmas and Holiday Season! XO
Author & Recovery Advocate, Catherine Townsend-Lyon 🙂