Privileged access

charles outreach accept

Peg O’Connor offers an interesting perspective on self-trust in addiction.

Complicating the matter is the belief that each person knows herself better than others can know her. In philosophy we call this “privileged access.” On this view, each person has an access to her beliefs, desires, thoughts, emotions that no one else can have. Each of us can turn a light to even the darkest, most remote corners of our mind; no one else can see those corners and what lurks there.  On that basis of privileged access, each person can say, “I have the best perspective on Who I Am.”

However, the relationship between privileged access and perspective is muddy, and confounds the question of how much trust to have in myself.

I found myself experiencing a little ambivalence reading this. Reflecting on my own behavior and those of clients, so many decisions look and sound like acts of self trust. Running our lives into the ground, asking for help and then disregarding other’s experience and advice looks like hubris

In truth, when I disregarded suggestions given by others, it wasn’t that I had so much trust in myself. Rather, I had less trust that others fully appreciated my circumstances, options, needs, goals, motives, etc. On a scale of 1 to 10 my self-trust may have only been a 2, but my trust in your accurate understanding was only a 1.5.

However, it looks like there isn’t an way around the matter.

So, given all these complications, how can one end this vicious cycle of unreliability–>lack of self-trust –>untrustworthiness –>unreliability…? It involves embracing something of a paradox. Sometimes one has to trust others before she can trust herself. In a sense, one may have to borrow the trust someone else has in her until she can begin to generate it for herself.

The person who sees herself as untrustworthy may need to grant that someone else may have a useful perspective on her. Another has some distance and hence perspective on us. This is the equivalent of holding the printed page further away from the face.

That reminded me of two things:

First, Nadia Bolz-Weber’s observation, “I don’t think faith is given in sufficient quantity to individuals necessarily. I think it’s given in sufficient quantity to communities.”

Second, Bill White talking about the recovery coaches of Project Safe and their process of developing “hope-engendering relationships”.

It strikes me that we’re asking these very scared and frightened people to grant us “privileged access.” This is an honor and a gift. Helpers who treat it as an honor and a gift are much more likely to earn that trust.

O’Connor tosses in a little folk-wisdom from Aristotle:

More concretely, Aristotle has some useful suggestions. If we become who we are by what we do, we should act in different ways if we want to become different people. Aristotle instructs us to act as a virtuous good person does even if we do not yet have the same character. By mimicking, we can begin to act in ways that can become virtuous as we begin to develop a virtuous character. This is the philosophical forerunner of “fake it until you can make it.”

2014’s top posts: #7

The evidence-base for 12 step recovery

photo credit: Jeff Tabaco
photo credit: Jeff Tabaco

There’s a fresh round of attacks on AA as pseudo-science in need of sober debunking. All based on one book that is getting impressive publicity. The book may contain references to support its attacks, but the interviews and articles do not. The absolute language (“everyone” and “never”) hint that this may not be the objective analysis it’s reported to be. Anna David makes the case that it’s a “hit job”.

The one source he does identify is the Cochrane Review.

Problems with the Cochrane Review of AA

About 5 years ago, I saw Sarah Zemore give a presentation that very effectively rebutted the Cochrane Review of the evidence for the effectiveness of 12 step groups. It was powerful and well organized. Here are her slides and here’s video of the presentation. (It’s old school. You have to download a mega-file.)

She made the following points in her introduction:

  • It was limited only to randomized trials and ignored the overwhelming observational evidence.
  • It included one of Zemore’s studies which was NOT a randomized study of AA.
  • She acknowledged that the randomized evidence is ambiguous.
  • Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
  • The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
  • Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It’s just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it’s an evidence based practice.

AA and the 6 Formal Criteria for Establishing Causation

Zemore’s content was summarized in an article about the conference:

Zemore presented Kaskutas’ (2009) article, “Alcoholics Anonymous Effectiveness: Faith Meets Science.” Noting diverging conclusions about AA’s effectiveness in the literature, Zemore presented Kaskutas’ approach to evaluating the evidence about AA, highlighting many categories of evidence. She took as the framework for evaluating the research 6 formal criteria for establishing causation described in Mausner and Kramer (1985): (1) strength of the association, (2) dose-response relationship, (3) consistency of the association, (4) correct temporal ordering, (5) specificity of the association, and (6) coherence with existing information. Strong evidence for Criteria 1– 4 and 6 was presented. Evidence for Criterion 5 was reported as mixed. Emphasis was made on the totality of the evidence in favor of AA as a causal agent of abstinence. This quote from the 2009 article summarizes the findings:

… the evidence for AA effectiveness is strong: rates of abstinence are approximately twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship. (criteria 6, plausibility). (Kaskutas, 2009, p. 155)

Reviewing the Evidence

The article goes on to summarize the knowledge presented as follows:

  • The preponderance of evidence supports the causal pathway that AA attendance leads to abstinence (Kaskutas, Zemore).
  • 12-Step affiliation significantly enhances the odds of sustaining abstinence for multiple years among polysubstance-dependent individuals (Laudet).
  • 12-Step involvement yields benefits above and beyond meeting attendance (Kaskutas, Zemore, Laudet)—and this is especially important for women (Laudet).
  • 12-Step attendance declines over time (Laudet, Kelly). Patterns of AA and NA attendance mirror patterns of treatment attendance with multiple stop-and-start episodes (Laudet).
  • A substantial minority of recovering substance abusers in the community do not participate in 12-Step programs (Laudet).
  • For adolescents, the relationship between AA meeting attendance and percent days abstinent increase in linear and positive direction at 6 months and 12 months posttreatment (Kelly).
  • A combination of treatment and AA is most effective (Kaskutas, Zemore).
  • Among adolescents, early posttreatment attendance, even in relatively small amounts, predicts long-term helpful outcomes. Consistent attendance over time predicts favorable outcomes (Kelly).
  • Three or more AA/NA meetings per week are optimal and associated with complete abstinence. However, even one or two meetings per week are associated with sharp increases in abstinence (Kelly, White).
  • Of 1.9 million people who are addicted to drugs or alcohol, only 18% are alcohol only and only 36% are drug only (White).
  • Those who state AA is helpful have better drinking outcomes. Those who state AA is not helpful have poorer drinking outcomes (Robinson).
  • Addiction severity predicts participation in AA and NA among adults (Robinson) and adolescents (Kelly).
  • Individuals who benefit from AA identify the importance of being in a group of sober people, see AA as a source of support, benefit from others’ experiences, and search for AA meetings and members with whom they find compatibility (Robinson).

Mutual Aid Mechanisms for Change

Bill White has summarized research on AA’s various mechanisms of change (Look at page 128. It includes citations.):

  • problem recognition and commitment to change;
  • regular re-motivation to continue change efforts;
  • counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
  • sustained self-monitoring;
  • increased spiritual orientation;
  • enhanced coping skills, particularly the recognition of high-risk situations and stressors;
  • increased self-efficacy;
  • social support that offsets the influence of pro-drinking social networks;
  • helping others with alcohol and other drug problems;
  • exposure to sober role models and experience-based advice on how to stay sober;
  • participation in rewarding sober activities;
  • 24-hour accessibility of assistance; and
  • potentially lifelong supports that do not require financial resources.

The Bottom Line

We’ve still got a lot to learn, but here’s some of what we know:

  • Is 12-step effective at initiating recovery? – YES
  • Are other approaches effective at initiating recovery? – YES
  • Is 12-step involvement associated with maintaining abstinence? – YES
  • Are other approaches associated with maintaining abstinence? – I haven’t seen the evidence.
  • Do 12-step programs work for everyone? – NO
  • Does anything work for everyone? – NO
  • Are there other paths to recovery? – YES
  • Do some people initiate recovery with one approach and maintain recovery by other means? – YES

We should continue to research 12-step recovery and other approaches. Learning more about the factors that contribute to the benefits of 12-step involvement might help in developing recovery maintenance strategies to help people who won’t attend 12-step groups or don’t benefit from 12-step groups.

UPDATE: DJMacUK’s comment is so good, I wanted to add it to the post to be sure you don’t miss it.

As far as randomised controlled trials go, it’s not just contamination of the control group that makes it hard to study AA. It’s a bit of a catch 22 with complex interventions like mutual aid. Keith Humphries makes good points on this: Some of this is quote and some paraphrase.

It is difficult to generalise because, most notably, of their extensive exclusion criteria ending up with a small and unrepresentative subset of patients. E.g. Exclude those with mental health disorders, physical health problems: exactly the sort of patients seen every day in treatment.

The common conviction that rcts always generate more accurate estimates of treatment effects is simply incorrect. The NEJM, perhaps the most respected source of controlled clinical trials in the world recently published literature reviews comparing the observed outcomes of medical treatments that had been studied both by randomised trials and by other evaluation approaches. Across methodologies, outcome results were almost always similar (Benson & Hartz, 2000; Concato, Shah and Horwitz, 2000)

Shifting sands: The idea that treatments are applied by outside forces before change begins and are then not affected by any subsequent changes in the patient is poorly matched to chronic dynamic disorders like addiction in which patient factors (e.g motivation, progress or regress) and treatment factors are in constant interplay (Moos 1997) Such processes are easier to understand when patients have the option of choosing which treatments they want, how they want them, when they want them and so forth, all of which is impossible in the context of a typical RCT.

RCTs depend on professional control of who receives the intervention and when and by definition, mutual aid is not professionally controllable. Participation in self help cannot specifically be denied to ‘controls’ in the way that a medication or procedure can be. Patients in the non mutual aid group arm have often gone to mutual aid anyway (this contaminated some of the project match data)

Privileged access

charles outreach accept

Peg O’Connor offers an interesting perspective on self-trust in addiction.

Complicating the matter is the belief that each person knows herself better than others can know her. In philosophy we call this “privileged access.” On this view, each person has an access to her beliefs, desires, thoughts, emotions that no one else can have. Each of us can turn a light to even the darkest, most remote corners of our mind; no one else can see those corners and what lurks there.  On that basis of privileged access, each person can say, “I have the best perspective on Who I Am.”

However, the relationship between privileged access and perspective is muddy, and confounds the question of how much trust to have in myself.

I found myself experiencing a little ambivalence reading this. Reflecting on my own behavior and those of clients, so many decisions look and sound like acts of self trust. Running our lives into the ground, asking for help and then disregarding other’s experience and advice looks like hubris

In truth, when I disregarded suggestions given by others, it wasn’t that I had so much trust in myself. Rather, I had less trust that others fully appreciated my circumstances, options, needs, goals, motives, etc. On a scale of 1 to 10 my self-trust may have only been a 2, but my trust in your accurate understanding was only a 1.5.

However, it looks like there isn’t an way around the matter.

So, given all these complications, how can one end this vicious cycle of unreliability–>lack of self-trust –>untrustworthiness –>unreliability…? It involves embracing something of a paradox. Sometimes one has to trust others before she can trust herself. In a sense, one may have to borrow the trust someone else has in her until she can begin to generate it for herself.

The person who sees herself as untrustworthy may need to grant that someone else may have a useful perspective on her. Another has some distance and hence perspective on us. This is the equivalent of holding the printed page further away from the face.

That reminded me of two things:

First, Nadia Bolz-Weber’s observation, “I don’t think faith is given in sufficient quantity to individuals necessarily. I think it’s given in sufficient quantity to communities.”

Second, Bill White talking about the recovery coaches of Project Safe and their process of developing “hope-engendering relationships”.

It strikes me that we’re asking these very scared and frightened people to grant us “privileged access.” This is an honor and a gift. Helpers who treat it as an honor and a gift are much more likely to earn that trust.

O’Connor tosses in a little folk-wisdom from Aristotle:

More concretely, Aristotle has some useful suggestions. If we become who we are by what we do, we should act in different ways if we want to become different people. Aristotle instructs us to act as a virtuous good person does even if we do not yet have the same character. By mimicking, we can begin to act in ways that can become virtuous as we begin to develop a virtuous character. This is the philosophical forerunner of “fake it until you can make it.”

What lifts people out of addiction?

Ernie Kurtz just published a great piece in Salon, but that’s for tomorrow. For today, here’s a repost of a 2006 post linking to a great talk by Rabbi and doctor Abraham Twerski on spirituality and recovery.

========================

twerski1As founder and medical director emeritus of Gateway Rehabilitation Center, Dr. Twerski spoke last month at the center’s Recovery Breakfast, on the topic ‘Will Chemical Blockers Eliminate the Need for AA?’ Here are his comments.

He opens with this:

When I was in medical school, my professor of pharmacology asked me what my plans for the future were, and I told him l was planning to become a psychiatrist. He said, “One day, we’re going to produce a pill that will put you all out of business.” Well, that’s not quite what happened. Rather, they produced a number of pills that made my business skyrocket.

Does it matter whether it’s viewed as a disease?

We are all one by JohnnyRokkit

The maker on The Anonymous People recently wrote:

“Is addiction a disorder, a matter of human frailty or something else?”

This debate about whether addiction is a disease or a matter of choice continues to garner headlines and direct our collective discussion away from the only thing that really matters: “How do people enter recovery from addiction and stay well?”

He points to the fact that addicts are dying and there are “23.5 million people in recovery.”

About that number, I’ve written about it before. Now, Young People in Recovery throw a little cold water on it:

“There are 23 million people in long-term recovery in the United States.” This widely cited statistic, sourced from a 2012 survey conducted by the Partnership at Drugfree.org and the New York Office on Alcoholism and Substance Abuse Services (OASAS), is often used to justify the need for increased recovery support services in the United States. However, in fact, what this survey actually asked to adults (ages 18 and over) was, “Did you once have a problem with drugs or alcohol, and no longer do?” Each respondent who answered “Yes” to this survey question has subsequently been labeled by the recovery community as a person in “long term recovery.” This begs the question: if a person has struggled with drugs or alcohol at one point in their life, is he or she automatically “in recovery”?

I think it does matter that it’s a disease and I think it matters that we distinguish between those with the chronic, impairing illness of addiction. I tend to believe that failing to distinguish will actually add to stigma. It will perpetuate the conversations that sound something like, “Greg, when your Uncle Tom was in the Navy, he drank too much and got into some trouble. Then he had kids and knocked it off. Why can’t you just do the same?” The reason they can’t do the same was that Uncle Tom was a problem drinker and Greg is an alcoholic.

Non-alcoholics using the drinking experience of non-alcoholics (themselves or others) to understand the experience of alcoholics only increases stigma.

It’s not a different degree of the same thing. It’s a different kind of thing.

In my experience, it’s only when people understand that it’s a different kind of thing—that the experience of the alcoholic cannot be understood by reflecting on your own experience of drinking too much in college—that stigma can be challenged.

So, to me, it’s a political fiction and reasonable people can disagree on whether it’s a useful political fiction. It reminded me of this old post.

Recovering community as political fiction

Ta-Nehisi Coates explores the challenges and political fiction of political movements by unpacking this passage from a feminist:

“She, who is so different from myself, is really like me in fundamental ways, because we are both”: This is the feminist habit of universalizing extravagantly–making wild, improbable leaps across chasms of class and race, poverty and affluence, leisured lives and lives of toil to draw basic similarities that stem from the shared condition of sex…

Inevitably, the imagined Woman fell short of the actualities of the actual woman it was supposed to describe, and inevitably, the identification between the feminist who spoke and the woman she spoke for turned out to be wishful, once those other women spoke up…

But although the Woman at the heart of feminism has been a fiction like any political fiction (“workers of the world,” “we the people”), it has been a useful fiction, and sometimes a splendid one. Extravagant universalizing created an imaginative space into which otherwise powerless women could project themselves onto an unresponsive political culture….

I’ve sometimes struggled with the recovery advocacy movement suffering from the same thing. I think you could substitute “woman”, “feminist”, etc with recovering people and it would be pretty accurate.

We often struggle with how inclusive to make definitions of recovery, who we include in the “community”, etc.

This push to universalize recovery has, I think, been helpful. It’s pushed many people in the recovering community to think of themselves as something larger than their small group and how more people might be helped. (It’s worth noting that Bill Wilson has been described as obsessed with how to reach and bring more people into recovery.) But, it has its limits and, at some point, I suspect it could be harmful. The same walls that inhibit inclusiveness also serve as a container for shared identities, concerns, sentiments, etc. So, I think some caution is probably a good thing.

Ta-Nehisi offers this thought:

But what I like about her analysis is that it doesn’t stop at noting the very obvious point, that political fictions don’t live up to realities.Instead she pushes on to assert that people create political fictions for actual reasons, and often those fictions have actual positive results.

Recovery Management extends therapeutic reach

Lambert's PieYesterday’s post on addiction counseling as community organization got me thinking about something I’d heard from a Scott Miller presentation.

Miller argued that treatment outcomes are due to the following factors in the following proportions:

  • 40%: client and extratherapeutic factors (such as ego strength, social support, etc.)
  • 30%: therapeutic relationship (such as empathy, warmth, and encouragement of risk-taking)
  • 15%: expectancy and placebo effects
  • 15%: techniques unique to specific therapies

Part of his argument was that we can’t control that 40% related to client and external factors, and we spend tons of time and capital arguing about the 15% related to specific therapies. He argues that we should spend much more time on the 45% we have more control over, hope and the alliance.

Here’s what I was thinking—that recovery management attends to that 45% plus the 40% Miller says is out of our hands. Bill White calls on us to shape those external factors. The attention to family, community, social, vocational, educational and other factors extends our reach.

Its worth noting that Physician Health Programs do this too, by creating social peer support (caduceus groups) and support within the workplace.

Addiction Counseling as Community Organization

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A few recent posts have put Bill White’s paper on Addiction Counseling as Community Organization on my mind.

First, was a post where I wondered if we were at risk for recovery capital becoming a proxy for class. I worried that this could lower expectations for people with lower socioeconomic status and be used as a justification for different standards of care.

Then, a study on the power of access to transportation as a factor in exiting poverty. This got my gears turning about the impact of these kinds of external factors on addiction treatment outcomes.

Next was a post with a rather heated exchange in the comments that discussed socioeconomic class differences in responses to treatment and what to do about them.

And then, a friend shared this study on racial disparities in treatment outcomes:

More than one-third of the approximately two million people entering publicly funded substance abuse treatment in the United States do not complete treatment. Additionally, racial and ethnic minorities with addiction disorders, who constitute approximately 40 percent of the admissions in publicly funded substance abuse treatment programs, may be particularly at risk for poor outcomes. Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability.

And, of course, addiction treatment isn’t the only aspect of health that’s affected by class. Just today, The Atlantic posted the following:

Brookings economist Barry Bosworth crunches the data on income and lifespans for the Wall Street Journal, and the numbers tell three clear stories.<

  1. Rich people live longer.
  2. Richer people’s lifespans are growing at a faster rate.
  3. The problem is worse for women than for men.

What do we do about this? Do we lower our hopes and expectations for people with lower socioeconomic status?

The Health Affairs article on disparities calls for more services:

States could also offer providers incentives to address barriers to completion of outpatient treatment. For example, homelessness and low education are particularly prevalent among blacks and Hispanics and are contributors to lower completion rates in these groups. Future research might explore whether broadened access to resources such as supported housing and vocational training are cost-effective strategies for improving outcomes and reducing disparities. Efforts to improve the tracking of individual patients could increase retention and improve outcomes, particularly for homeless populations.

Bill’s emphasis is a little different. He calls on us to raise our expectations of ourselves and the system while focusing on recovery and the community as the locus of healing. (Rather than emphasizing treatment at the expense of wellness and glorifying ourselves.) [emphasis mine]

Addiction treatment must always adapt to the evolving context in which it finds itself. Such redefinition may push treatment toward the experience of retreat and sanctuary in one period and toward the experience of deep involvement in the community in another. I would suggest that the focus of addiction counseling today should not be on addiction recovery-that process occurs for most people through maturation, an accumulation of consequences, developmental windows of opportunity for transformative or evolutionary change, and through involvement with other recovering people within the larger community. The focus of addiction counseling today should instead be on eliminating the barriers that keep people from being able to utilize these natural experiences and resources. Our interventions need to shift from an almost exclusive focus on intervening in the addict’s cells, thoughts and feelings to surrounding and involving the addict in a recovering community.

6a00d8351b273153ef01156f302741970c-800wiIn another paper. Bill White identified 4 tasks of treatment and recovery:

  1. Recovery from the other genetic, biochemical, social, psychological, or familial influences which initially contributed to the development and trajectory substance problems
  2. Recovery from the adverse psychosocial consequences of the substance use
  3. Recovery from the pharmacologic effects of the substances themselves
  4. Recovery from an addictive culture

When I saw this list for the first time, I was struck by the intuitive truth it organized and articulated. I was also struck by how it illuminated the scope of the treatment and early recovery—”social, psychological, familial . . . psychosocial consequences . . . addictive culture”.

That paper on Addiction Counseling as Community Organization was really an early step in the development of his concept of Recovery Management, which is explained more fully here. In this paper, Bill shifts the language to “community renewal.”

A major focus of RM (Recovery Management) is to create the physical, psychological, and social space within local communities in which recovery can flourish. The ultimate goal is not to create larger treatment organizations, but to expand each community’s natural recovery support resources. The RM focus on the community and the relationship between the individual and the community are illustrated by such activities as:

  • initiating or expanding local community recovery resources, e.g., working with A.A./N.A. Intergroup and service structures (Hospital and Institution Committees) to expand meetings and other service activities; African American churches “adopting” recovering inmates returning from prison and creating community outreach teams; educating contemporary recovery support communities about the history of such structures within their own cultures, e.g., Native American recovery “Circles,” the Danshukai in Japan;
  • introducing individuals and families to local communities of recovery;
  • resolving environmental obstacles to recovery;
  • conducting recovery-focused family and community education;
  • advocating pro-recovery social policies at local, state, and national levels;
  • seeding local communities with visible recovery role models;
  • recognizing and utilizing cultural frameworks of recovery, e.g., the Southeast Asian community in Chicago training and utilizing monks to provide post-treatment recovery support services; and
  • advocating for recovery community representation within AOD-related policy and planning venues.

It can be overwhelming. But, the alternative is despair.

Driving out of poverty

aiga_bus_on_grn_circle-512A new study on the relationship between access to transportation and exiting poverty caught my attention:

But a new study co-led by myself; Evelyn Blumenberg from the University of California, Los Angeles; and Casey Dawkins from the University of Maryland suggests there is at least one group that may need help to drive more, not less: low-income residents of high-poverty neighborhoods.

Our evidence comes from two Department of Housing and Urban Development demonstration programs: Moving to Opportunity for Fair Housing and Welfare to Work Vouchers. Both were designed to test whether housing choice vouchers—that is, subsidies that allowed participants to choose where they live—propelled low-income households into greater economic security.

Taken together, data sets from these studies allowed us to examine neighborhood quality, neighborhood satisfaction, and employment outcomes for almost 12,000 families from 10 cities: Atlanta, Augusta, Baltimore, Boston, Chicago, Fresno, Houston, Los Angeles, New York, and Spokane.

The results? Housing voucher recipients with cars tended to live and remain in higher-opportunity neighborhoods—places with lower poverty rates, higher social status, stronger housing markets, and lower health risks. Cars are also associated with improved neighborhood satisfaction and better employment outcomes. Among Moving to Opportunity families, those with cars were twice as likely to find a job and four times as likely to remain employed.

The importance of automobiles arises not due to the inherent superiority of driving, but because public transit systems in most metropolitan areas are slow, inconvenient, and lack sufficient metropolitan-wide coverage to rival the automobile.

When asked about Dawn Farm’s success, we make it clear we’ve had a lot of good fortune, a lot of help from good friends and we’ve made some good decisions. We also point out that we are fortunate to be in a community with good public transportation and job opportunities.

I have a few thoughts. First, this speaks to the challenge of trying to replicate our housing and support services in a different environment.

Second, so many alcoholics seeking treatment have suspended driver licenses and the suspensions seem to be getting longer and longer. I’m not necessarily a proponent of easing those suspensions—drunk driving is dangerous, though sobriety courts seem like s good strategy for managing the risk. But, this study speaks to how debilitating losing a license can be in socio-economic terms. But, how about in terms of recovery?

This also speaks to the power of the informal networks that people find in mutual aid groups that help with transportation.

The evidence-base for 12 step recovery

photo credit: Jeff Tabaco
photo credit: Jeff Tabaco

There’s a fresh round of attacks on AA as pseudo-science in need of sober debunking. All based on one book that is getting impressive publicity. The book may contain references to support its attacks, but the interviews and articles do not. The absolute language (“everyone” and “never”) hint that this may not be the objective analysis it’s reported to be. Anna David makes the case that it’s a “hit job”.

The one source he does identify is the Cochrane Review.

Problems with the Cochrane Review of AA

About 5 years ago, I saw Sarah Zemore give a presentation that very effectively rebutted the Cochrane Review of the evidence for the effectiveness of 12 step groups. It was powerful and well organized. Here are her slides and here’s video of the presentation. (It’s old school. You have to download a mega-file.)

She made the following points in her introduction:

  • It was limited only to randomized trials and ignored the overwhelming observational evidence.
  • It included one of Zemore’s studies which was NOT a randomized study of AA.
  • She acknowledged that the randomized evidence is ambiguous.
  • Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
  • The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET.
  • Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

It was important for me because supporters of Twelve-step Facilitation are too often painted as the equivalent of intelligent design advocates. It’s just not so and the evidence in this presentation made this unequivocally clear. Twelve-step Facilitation is not the only approach that works, but it’s an evidence based practice.

AA and the 6 Formal Criteria for Establishing Causation

Zemore’s content was summarized in an article about the conference:

Zemore presented Kaskutas’ (2009) article, “Alcoholics Anonymous Effectiveness: Faith Meets Science.” Noting diverging conclusions about AA’s effectiveness in the literature, Zemore presented Kaskutas’ approach to evaluating the evidence about AA, highlighting many categories of evidence. She took as the framework for evaluating the research 6 formal criteria for establishing causation described in Mausner and Kramer (1985): (1) strength of the association, (2) dose-response relationship, (3) consistency of the association, (4) correct temporal ordering, (5) specificity of the association, and (6) coherence with existing information. Strong evidence for Criteria 1– 4 and 6 was presented. Evidence for Criterion 5 was reported as mixed. Emphasis was made on the totality of the evidence in favor of AA as a causal agent of abstinence. This quote from the 2009 article summarizes the findings:

… the evidence for AA effectiveness is strong: rates of abstinence are approximately twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship. (criteria 6, plausibility). (Kaskutas, 2009, p. 155)

Reviewing the Evidence

The article goes on to summarize the knowledge presented as follows:

  • The preponderance of evidence supports the causal pathway that AA attendance leads to abstinence (Kaskutas, Zemore).
  • 12-Step affiliation significantly enhances the odds of sustaining abstinence for multiple years among polysubstance-dependent individuals (Laudet).
  • 12-Step involvement yields benefits above and beyond meeting attendance (Kaskutas, Zemore, Laudet)—and this is especially important for women (Laudet).
  • 12-Step attendance declines over time (Laudet, Kelly). Patterns of AA and NA attendance mirror patterns of treatment attendance with multiple stop-and-start episodes (Laudet).
  • A substantial minority of recovering substance abusers in the community do not participate in 12-Step programs (Laudet).
  • For adolescents, the relationship between AA meeting attendance and percent days abstinent increase in linear and positive direction at 6 months and 12 months posttreatment (Kelly).
  • A combination of treatment and AA is most effective (Kaskutas, Zemore).
  • Among adolescents, early posttreatment attendance, even in relatively small amounts, predicts long-term helpful outcomes. Consistent attendance over time predicts favorable outcomes (Kelly).
  • Three or more AA/NA meetings per week are optimal and associated with complete abstinence. However, even one or two meetings per week are associated with sharp increases in abstinence (Kelly, White).
  • Of 1.9 million people who are addicted to drugs or alcohol, only 18% are alcohol only and only 36% are drug only (White).
  • Those who state AA is helpful have better drinking outcomes. Those who state AA is not helpful have poorer drinking outcomes (Robinson).
  • Addiction severity predicts participation in AA and NA among adults (Robinson) and adolescents (Kelly).
  • Individuals who benefit from AA identify the importance of being in a group of sober people, see AA as a source of support, benefit from others’ experiences, and search for AA meetings and members with whom they find compatibility (Robinson).

Mutual Aid Mechanisms for Change

Bill White has summarized research on AA’s various mechanisms of change (Look at page 128. It includes citations.):

  • problem recognition and commitment to change;
  • regular re-motivation to continue change efforts;
  • counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
  • sustained self-monitoring;
  • increased spiritual orientation;
  • enhanced coping skills, particularly the recognition of high-risk situations and stressors;
  • increased self-efficacy;
  • social support that offsets the influence of pro-drinking social networks;
  • helping others with alcohol and other drug problems;
  • exposure to sober role models and experience-based advice on how to stay sober;
  • participation in rewarding sober activities;
  • 24-hour accessibility of assistance; and
  • potentially lifelong supports that do not require financial resources.

The Bottom Line

We’ve still got a lot to learn, but here’s some of what we know:

  • Is 12-step effective at initiating recovery? – YES
  • Are other approaches effective at initiating recovery? – YES
  • Is 12-step involvement associated with maintaining abstinence? – YES
  • Are other approaches associated with maintaining abstinence? – I haven’t seen the evidence.
  • Do 12-step programs work for everyone? – NO
  • Does anything work for everyone? – NO
  • Are there other paths to recovery? – YES
  • Do some people initiate recovery with one approach and maintain recovery by other means? – YES

We should continue to research 12-step recovery and other approaches. Learning more about the factors that contribute to the benefits of 12-step involvement might help in developing recovery maintenance strategies to help people who won’t attend 12-step groups or don’t benefit from 12-step groups.

UPDATE: DJMacUK’s comment is so good, I wanted to add it to the post to be sure you don’t miss it.

As far as randomised controlled trials go, it’s not just contamination of the control group that makes it hard to study AA. It’s a bit of a catch 22 with complex interventions like mutual aid. Keith Humphries makes good points on this: Some of this is quote and some paraphrase.

It is difficult to generalise because, most notably, of their extensive exclusion criteria ending up with a small and unrepresentative subset of patients. E.g. Exclude those with mental health disorders, physical health problems: exactly the sort of patients seen every day in treatment.

The common conviction that rcts always generate more accurate estimates of treatment effects is simply incorrect. The NEJM, perhaps the most respected source of controlled clinical trials in the world recently published literature reviews comparing the observed outcomes of medical treatments that had been studied both by randomised trials and by other evaluation approaches. Across methodologies, outcome results were almost always similar (Benson & Hartz, 2000; Concato, Shah and Horwitz, 2000)

Shifting sands: The idea that treatments are applied by outside forces before change begins and are then not affected by any subsequent changes in the patient is poorly matched to chronic dynamic disorders like addiction in which patient factors (e.g motivation, progress or regress) and treatment factors are in constant interplay (Moos 1997) Such processes are easier to understand when patients have the option of choosing which treatments they want, how they want them, when they want them and so forth, all of which is impossible in the context of a typical RCT.

RCTs depend on professional control of who receives the intervention and when and by definition, mutual aid is not professionally controllable. Participation in self help cannot specifically be denied to ‘controls’ in the way that a medication or procedure can be. Patients in the non mutual aid group arm have often gone to mutual aid anyway (this contaminated some of the project match data)

Not evidence-based for recovery

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

Abstinence-oriented treatment has taken a beating in the media recently. There have been lots of assertions that medication maintenance approaches are THE evidence-based approaches and that abstinence-based approaches lack evidence and kill addictions. We know this isn’t true and have posted repeatedly on the subject.

Right on time, Drug and Alcohol Findings reviews a recently published Cochrane report on buprenorphine vs. methadone maintenance:

Main Findings

Dosing levels were flexible in 11 studies which compared the two medications. Across these, the chances of a patient leaving treatment during study periods ranging from six weeks to a year was 17% lower on methadone. This means for example that if 60 out of 100 patients are retained on buprenorphine, had they instead been prescribed methadone, typically another 12 would have stayed in treatment. Results were similar and more consistent across the five double-blind studies in which neither patients nor clinicians were told which medication the patient was taking. Among the remaining six non-blinded studies, methadone’s retention advantage was not quite statistically significant and varied considerably between studies.

Across the eight flexible-dose studies which provided this data, numbers of urine tests indicative of continuing heroin use only slightly and non-significantly favoured buprenorphine. The same was true for the patients’ own accounts of their heroin use. There were also no significant differences in use of cocaine or benzodiazepines, though in both cases there was a slight advantage for methadone. Just two studies contributed to the analysis of criminal activity, cumulating to no significant difference between the medications.

In the fixed-dose studies which compared buprenorphine with methadone, retention was only significantly different (patients stayed longer on methadone) in the low-dose comparisons of less than 16mg of buprenorphine versus less than 40mg of methadone. In no dose range did one medication versus the other result in significantly fewer urine tests or self-reports from the patients indicative of heroin use.

Across the 11 studies which compared buprenorphine to a placebo, buprenorphine in whatever dose range retained patients better in treatment. However, only high-dose (at least 16mg per day) buprenorphine led to fewer urine tests indicative of continuing illegal heroin use.

This review looked only at retention on medication and reductions in drug  use. So, the bar is set pretty low. So . . . here’s what we’ve learned from the evidence-base:

  • Retention: Buprenorphine achieved a retention rate of 60% with study periods of as brief as 6 weeks and no longer than 1 year. Common sense would suggest that, if 60% is the average, the one year retention rate is significantly lower than that.
  • Drug Use: Buprenorphine only reduced drug use at high doses–16mg or higher.

This is now familiar.

Researchers set the bar low and a drug therapy does not reach that bar. The solution is that the patient never stops taking the drug. The drug therapy still doesn’t reach the bar and the solution is higher doses of the drug.

First, with methadone. We shift from methadone detox to methadone maintenance. Then the evidence-base pushes higher doses.

Now, with buprenorphine. The evidence-base finds “near universal relapse” when using it as a detox tool and we’re pushed toward buprenorphine maintenance. Now, the evidence-base finds continued drug use and the solution is higher doses.

Here’s Drug and Alcohol Findings‘ summary of the comparison between buprenorphine and methadone:

. . . patients dependent on large doses of opiates may find it [buprenorphine] inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the ‘wrapped in cotton wool’ feeling typical of heroin are likely to prefer methadone; those who value a clearer head might prefer buprenorphine.

I guess a clear head is relative.

On life after medication-assisted treatment (The UK has been relying on maintenance for decades and is moving away from it because maintenance patients have not been successfully re-integrating into society.):

Patients aiming for a relatively rapid break from all opiate-type drugs might do best to opt for buprenorphine initially, or to switch to it after stabilising on methadone, but have to accept the risk that instead they will drop out and return to dependence on illegal drugs.

. . . buprenorphine’s ability to help patients take a half-step away from reliance on opiate-type effects and its greater ‘leavability’ could become valued more, while methadone’s ‘stickability’ is being seen not (or not only) as a strength, but a liability. However, buprenorphine’s leavability is itself a liability if it means (as in this British study) that many more patients drop out and still only a small minority leave after successful detoxification.

The problem is that this isn’t what patients are looking for. They want their lives back. They want recovery. The evidence-base for these drugs is for reducing overdose, reducing drug use, reducing criminal activity and reducing disease transmission. They are not an evidence-based treatment for promoting recovery.

If what you want is an evidence-based treatment that’s associated with complete abstinence, low relapse rates and returning to employment, they exist and have a robust evidence-base. Health professionals and pilots have programs with outstanding outcomes. And, it doesn’t have to be expensive.

I’ll end with a reminder from a previous post about were I stand on maintenance treatments:

Just to be sure that my position is understood. I’m not advocating the abolition of maintenance treatments.

Here’s something I wrote in a previous post: “All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”