Pathways into and out of addiction

I am often asked, what is the best way to recover from addiction? There are as many pathways out of addiction as there are pathways into addiction. There is no single best or certain approach to recovery. For example, lapses and relapses are very common for any treatment approach. During the past four decades, this understanding has led me to develop clinical pragmatism.

As a clinician, my job has been to help people find an approach to dealing with addiction that is effective, possible, and sustainable. Early in my career, the struggle to find effective treatment approaches was played out against a backdrop of 12-step programs. This battle usually emerged as Alcoholics Anonymous versus professional treatment — a strictly abstinence approach versus something less strict and more mysterious. For example, recovering people battled with professionals who had little or no experience with the causes of addiction, total abstinence as a treatment outcome, or the use of medication during treatment.

Now, some of these battles still remain, but self-help groups and professionals have learned to work collaboratively in the best interest of recovering people — and argue less about what works best. A variety of research projects have demonstrated that there is no one best treatment. For example, new research shows that as Norman Zinberg, a seminal figure in the addiction field, often quipped, clinicians and self-help programs alike need to "meet people with addiction where they are and take them where they don't want to go!"

There is no "best" or one-size-fits-all mutual-help approach

A new longitudinal study published in the Journal of Substance Abuse Treatment reminds us, for example, that a variety of mutual help approaches seem to work about the same. In this study, the investigators examined different types of mutual support groups for people with alcohol use disorder. These included Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups. When the researchers controlled the participants' alcohol recovery goals at baseline, there were no significant outcome differences between groups. The authors concluded that the findings "…tentatively suggest that clinicians, the courts, and others who assist and advise those with alcohol use disorder (AUD) consider referral to a broad array of mutual help options including WFS, LifeRing, and SMART." Nevertheless, we need to interpret these results with caution.

Researchers must be careful to avoid interpreting the absence of treatment group difference as evidence that supports treatment parity. There are many reasons that research can fail to identify treatment group distinctions; for example, many different types of people in the groups, insufficient follow-up, and a variety of other technical issues can mask genuine differences among treatment groups. Science rarely advances by resting on a foundation of "no difference" findings.

Absent one specific treatment that best helps people to escape addiction, we need to work with the whole portfolio of change agents. Self-directed, other-directed, and mutual support approaches can influence people and their attempts to change. Medication assisted treatment works and should be considered for people who might benefit from this option.

People with addiction mostly change on their own. We see only a small segment of people with addiction in treatment or self/mutual-help groups. However, some people do change with the assistance of professional treatment. Sometimes people enter treatment after they have made some changes and want to understand how to maintain these changes. They often want to know what led to their addiction in the first place. Still others change with the help of mutual support groups. Ultimately these varied pathways out of addiction represent variations of personal responsibility.

Social support and self-help can sustain change

Research shows that people who escape addiction are usually motivated by one or more of the following losses: loss of health, loss of a loved one, loss of a job. Ultimately, professional treatment and 12-step programs shift attention from a loss focus — what not to do — to a system that emphasizes what to do. Treatment and self-help provide the social support to encourage the work of changing and maintaining change.

The brass ring of addiction treatment is to identify which person, with which intervention and treatment provider, at which moment in their addiction experience, will have the most favorable change outcomes. Treatment outcomes are explained in large part by the quality of the relationship between the person with addiction and their care provider (such as a therapist or sponsor) or 12-step group.

Participants in 12-step programs and psychotherapy alike must learn to shift their attention from what they have lost to a perspective that emphasizes what people in recovery can and need to do going forward. Importantly, 12-step programs provide the ever-present social support system to encourage the doing.

Follow me on Twitter @howard_shaffer

References

The Heart and Soul of Change: What Works in Therapy. American Psychological Association.

What Works for Whom: Tailoring Psychotherapy to the Person. Journal of Clinical Psychology, February 2011.

Quitting Cocaine: The Struggle Against Impulse. Howard J. Shaffer and Stephanie B. Jones, Lexington Books.

A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. Journal of Substance Abuse Treatment, May 2018.