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New Findings on 12-Step Treatment

The most popular model of substance abuse treatment in the United States is the 12-step approach. This approach grew out of AA and NA (Alcoholics Anonymous and Narcotics Anonymous) and involves encouraging patients to accept the disease model of addiction, or label themselves as "alcoholics" or "addicts" to attend 12-step meetings, to acquire and utilize a "sponsor," and to "work the steps." Two recent studies support the potential effectiveness of this treatment when carried out by mental health professionals. The first studied alcohol-dependent outpatients. The group of subjects that received 12-step treatment improved substantially. The second study focused on VA inpatients with alcohol and/or other substance use disorders. At the one-year follow up, the group of subjects that had received 12-step treatment improved significantly in many life areas. Approximately 80% reduced their alcohol consumption, 30% no longer met diagnostic criteria for a substance abuse disorder, 25% were completely abstinent, and roughly 25% improved on depression, anxiety, and/or employment status. If any of the percentages seem disappointingly low to you, it should be noted that these were dysfunctional patients. Many of the subjects were MICA patients, suggesting that 12-step treatment may be helpful for this subpopulation. Although this study had some major flaws (e.g. lack of random assignment to groups), it is a valuable first step toward evaluating the effectiveness of 12-step treatment for inpatients.

New Findings on "Self-Medication"

An important issue related to the assessment and treatment of the MICA patient is the self-medication hypothesis. The hypothesis asserts that at least some psychoactive substance users abuse alcohol or other drugs to decrease their psychological distress. A recent award-winning study conducted at SUNY-Albany lends support to this notion. A graduate student in psychology was distressed that all patients with an anxiety disorder who presented at the clinic at which she worked were turned away (and referred elsewhere) if they also suffered from an alcohol or drug problem. She designed and conducted a controlled, within-subject study with three patients, all of whom were diagnosed with both panic disorder and alcohol abuse. Although not a perfect study, it does increase our confidence that many chemical abusers self-medicate. This points to the importance of effectively treating other Axis I disorders if the MICA patients is to stay "clean and sober."

New Findings on Drug Abuse Treatment.

A Quantitative review of the empirical literature was recently completed on the effectiveness of psychosocial treatments for drug abuse. Which do you think was found to be the most effective: individual therapy, group therapy, or couples/family therapy? If you guessed "couples/family therapy," you are right. It's rarely true that drug addicts have little contact with their families. Families apparently are a major part of addicts' environments, so if you can treat not just the addicts, but their environments as well, you are cutting down the chance of relapse. Often, well-meaning family members say things that addicts interpret as overly critical or intrusive. This may increase stress and trigger self-medication with illicit substances. When relatives are taught about the addicts' disorder(s), they may learn to blame the disorder(s) instead of the addicts. This is especially relevant to MICA patients. When families are taught how to communicate more effectively, there should be less stress and more support. And with less stress and more support, there are likely to be fewer relapses of both the addiction and the other Axis 1 disorders.

New Approaches to Alcoholism Treatment

A sophisticated quantitative review was recently published on the effectiveness of various treatments for alcoholism. Perhaps surprisingly many standard treatments were found to be ineffective, including confrontational counseling and exploratory/insight-oriented psychotherapy. Many of the treatments found to be effective are often classified as cognitive-behavioral: social skills training, the community reinforcement approach, behavior contracting, and relapse prevention. The results of disulfiram (Antabuse) were mixed. Only when administered as part of a cognitive behavior incentive program was it consistently helpful. An example of such a program is a "disulfiram contract" signed by both husband and wife in which the husband agrees to take each day in front of his wife, and the wife agrees to (a) observe him, (b) show him appreciation and (c) refrain from mentioning past drinking or fears about future drinking. Cognitive behavior couples/family therapy was found to be more effective than its non-behavioral counterpart. One non-behavioral treatment found to be very effective was client-centered therapy. Another efficacious treatment is a new one called motivation enhancement therapy (or motivational interviewing). In fact, in one study on outpatients, this therapy was just as effective yet cheaper to provide than both 12-step treatment and cognitive-behavior therapy. Motivation enhancement therapy is a non-authoritarian approach in which the therapist utilizes both client-centered and cognitive behavioral techniques. Such techniques include both Rogerian reflection and Socratic questioning to help patients see that they are behaving in ways that are not consonant with the goals for themselves. This presumably leads to a feeling of dissonance within the patient, which in turn encourages patients to change in ways that they choose in order to reduce the feeling of dissonance.

In Conclusion

Unfortunately, new research recently completed that was aimed at giving clinicians hints on how to best match specific alcoholics/addicts with specific treatments yielded inconclusive results. In the absence of such data, clinicians should try to give the patient as much choice as possible among empirically supported approaches. Such research-backed treatments include both 12-step and some newer psychoeducational approaches. Chemical abusers often need to be taught life-management and coping skills that they lack. Also, the old notions-the patients are either "in treatment" or "out of treatment," and, if "out of treatment," that is their fault-may be outdated. An emerging view is that most patients are ambivalent about recovery, and that their motivational levels fluctuate. Fortunately, there are now proven techniques that we can utilize to boost and maintain motivation.

Many professionals now believe that confrontational approaches are counterproductive with MICAs because these patients are more fragile than non-MICAs. Again, confrontation has been shown to predict failure not with just MICAs, but with all alcoholics. Conversely, therapies utilizing a warm, empathic style where a patient gets to choose from a "menu" of therapeutic options appear to be much more effective. It may be that chemical abusers are very sensitive to criticism and tend to "cut their noses off to spite their faces" by "picking up." This suggests that treatment staff should give far more positive than negative feedback, and when giving corrective feedback, should try to provide it in a non-punitive, understated way. In their thoughtful, and helpful book, The Mentally Ill Chemical Abuser: Whose Client? (Lexington Books of New York), Jacqueline Cohen and Stephen Jay Levy give similar advice. They encourage staff to really listen to patients; be real with them, including shared feelings; have a sense of humor; and not to take themselves too seriously. In conclusion, the most recent literature suggests that those providing services to MICA patients should try to avoid making the same mistakes made by overly critical, bossy family members. In our zeal to help, our "over-criticalness" and bossiness could trigger self-medication and/or an exacerbation of other Axis I symptomology. Let's avoid bringing about exactly the opposite of what we're trying to accomplish!