Dr. Alan Wartenberg
I have practiced general internal medicine (GIM) for over 40 years, addiction medicine for 35 of those and exclusively addiction medicine for the last 20 or so. Wearing my GIM hat, I saw many patients who did not follow the pathways I recommended. Early in my practice, it seemed that I was mostly seeing overweight/obese patients with diabetes, hypertension and arthritis, all of whom would have benefited from diet/exercise and weight loss. However, few of them succeeded through lifestyle changes alone. While continuing to promote behavioral change, I was mindful of the need to control their blood sugars, reduce their blood pressure, and treat their arthritis pain. I had to have many options to provide them with; diet, exercise and mindfulness to be sure, but medication and other support in addition.
I believe that addiction medicine, as a field, has been remiss in this area. I have seen many of my colleagues view 12-step recovery as the only option to offer their patients. It is my first choice as well, but just as I am aware that not everyone succeeds with my first choices in the management of their medical issues, I am cautious of the limitations of 12-step programs for some patients. The informality and anonymity of these programs make studies of their efficacy difficult, but not impossible. Our best information is that about 25% of people who attend 12-step programs, particularly Alcoholics Anonymous, remain in these programs for as much as one year.1 For those who do, more than 75% will ultimately enter and remain in long-term recovery.2 Data on those with primary drug abuse appears to show a lower retention level.
There certainly may be a great deal of local variation with these numbers, but we do know that many of our patients are resistant to 12-step concepts such as surrender, a belief in the lifetime nature of addiction, and to the importance of spiritual precepts or of a “Higher Power” in recovery. Others may be resistant to attending groups on the basis of social phobia, religious objections to attending meetings in other places of worship and many other reasons.
Many non 12-step programs are available, ranging from formal therapy groups utilizing cognitive behavioral therapies, motivational enhancement and contingency management to mutual help groups such as SMART Recovery, Women for Sobriety, Secular Organizations for Sobriety and others. These programs are abstinence-based and may be appropriate for many of our patients who will either not initially attend, or do not remain in 12-step programs.3
A recent Diane Rehms show on NPR highlighted programs in which patients who consistently and repeatedly failed to benefit from 12-step treatment were consistently and repeatedly put back into the very same kind of treatment. Several guests, including both patients and health care professionals, complained that no effort was made to find alternatives for these patients.4 Early in my own career, a counselor emphasized to me and to our patients that treatment was not Burger King, and that you “couldn’t have it your way.” In fact, he was known to repeatedly bellow that it was “my way or the highway.”
A maxim in social work is to “treat the patient where they are at.” I believe that we as addiction treatment providers have something to learn from this approach. Patients who are resistant to 12-step concepts can and should be offered alternative pathways to recovery. Those who begin in 12-step treatment but fail to utilize it consistently over time should have their resistance explored, and often we can overcome their objections and resistance with education. However, when this does not succeed, we must be open to available alternatives.
As a field, we have often either been ignorant of the availability and utility of these other approaches, have failed to inform our patients of them or have even actively resisted such referral. Some of us have been overtly hostile to anything other than 12-step recovery techniques. All of us must be humbled by the obvious fact that the overwhelming majority of people with addiction never enter ANY form of treatment during their lifetimes. How tragic is it, then, that for the perhaps 20% of people with addiction who do seek help, that we do not offer them the widest range of available choices?
I urge those colleagues who are not familiar with these alternative approaches to educate themselves, as well as to work to broaden the available choices in their own communities and to make every effort to urge all of our patients to find the choices that work best for them. I have made the same recommendations to some of my colleagues who do refer to alternative programs, but fail to explore those patients’ appropriateness for 12-step programs. None of these programs are mutually exclusive, and I have had many patients attend Alcoholics Anonymous and SMART recovery meetings (or others).
In the preface to the 2nd edition of the Alcoholics Anonymous Big Book, the author states, “In all probability, we shall never be able to touch more than a fair fraction of the alcohol problem in all its ramifications. Upon therapy for the alcoholic himself, we surely have no monopoly.”5 I believe we all must take this advice to heart, open our minds and hearts to available and appropriate alternatives, and assist ALL of our patients in finding their own particular path to recovery and improved function for themselves. This will benefit our profession, our patients and society in general.
1. Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database of Systematic Reviews. 2006, Isues 3:CD005032.
2. Alcoholics Anonymous: Contemporary myths and misinterpretations, January 1, 2008. http://hindsfoot.org/recout01.pdf. Accessed February 2013.
3. White, W. & Kurtz, E. (2005). The Varieties of Recovery Experience
Chicago, IL:Great Lakes Addiction Technology Transfer Center. http://www.facesandvoicesofrecovery.org/pdf/White/2005-09_white_kurtz.pdf. Accessed February, 2013.
4. Inside Addiction Treatment. The Diane Rehm Show. February 11, 2013. http://thedianerehmshow.org/shows/2013-02-11/inside-addiction-treatment. Accessed February, 2013.
5. Alcoholics Anonymous. Alcoholics Anonymous, 4th Edition. New York: A.A. World Services, 2001.