Choice Theory Conference

It was my privilege yesterday to attend the Choice Theory Education Conference at the Hilton in Sacramento. I staffed a LifeRing literature table there, met with LifeRing convenors and future convenors, attended some of the sessions, and met some of the leading figures in the choice movement.

Georgellen Hofine, one of the oldest students of Choice Theory founder Dr. William Glasser (photo), personally welcomed me to the gathering. LifeRing keynote speaker and DVD author Dr. B. J. Davis was the closing speaker on the conference program, and I much enjoyed listening to his presentation and chatting with him informally.

Choice Theory advocates Resa Stendel Brown and Jack Harnden spoke about the application of Choice Theory in education. Author Mike Rice gave a talk on addiction. B. J. Davis, in addition to his own discussion of Choice Theory in addiction treatment settings, introduced a DVD showing how Reality Therapy (an earlier name for Choice Theory) was applied in a prison setting.

I took time out to meet and chat with convenors of the LifeRing meetings in Placerville and one of the Sacramento locations. One of the conference participants expressed determination to start a LifeRing meeting in Lodi. Two of the treatment professionals in attendance spoke of plans to start LifeRing meetings at their centers in the Sacramento area.

It was a very positive crowd, including quite a few people with an interest in addiction recovery, and I should have brought more books, as Empowering Your Sober Self sold out by noon.

The only shadow over the event was the news that Dr. Glasser himself, who had been scheduled as keynote speaker, had been admitted to the hospital with a cardiac issue. There is as of this writing no further news on his condition.

Well said, in Washington

The Bush years, by wide consensus, were a dismal era for science.  But by a strange paradox, some bright stars emerged in what is normally a dismal field under any administration: addiction science.  

One is the brilliant Nora Volkow, who brings a rare mix of research experience, clear thinking, and leadership ability to the National Institute on Drug Abuse (NIDA).  

Another is Mark Willenbring, Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  In a letter to the current New Yorker (the one with the cartoon of Obama as George Washington on the cover), Willenbring precisely skewers a piece that this normally astute mag published in its December 1 issue.  The article, titled "Special Treatment," by Amanda Fortini, featured a Los Angeles area deluxe treatment facility.  

After a string of well-worn 12-step platitudes about addiction and the difficulties of recovery, the owners of the facility claimed that in essence treatment could make no difference, everything depended on the addicted person's motivation.  So why bill the client for clinical services on top of the normal cost of luxury room and board? 

Willenbring's letter goes directly for the jugular.  He writes that the piece:

... shows the irony that paying more does not guarantee access to the most current therapies... The program that Fortini describes appears to base its services on a treatment model that is more than thirty years old .... Although clients may or may not receive some benefit, they are vulnerable to unnecessary relapse risk if more contemporary treatments are not also made available.  For example, research funded by the National Institutes of Health has identified several medications that reduce relapse in early recovery from alcohol dependence.  Newer behavioral approaches, such as cognitive-behavior therapy and motivational interviewing, also increase recovery and provide alternatives to the traditional Twelve Step approach (which in updated form is also effective).  This menu of services makes possible truly individualized treament and  increases client choice and engagement, but only if people have access to it.

The treatment program Fortini described in her article was so clinically clueless and bereft of ideas that the piece might have been a subliminal parody.  It isn't often that I get to cheer somebody in Washington for saying the right stuff.  Could this be the beginning of a change we can believe in?  

Humility R Us [NOT]

It's been six years since AA Trustee Dr. George Vaillant's article in the AA Grapevine, saying that "It doesn't hurt at the level of the GSO for AA to have humility and understand that 60 per cent do it without AA." Source. He was talking about the research finding that 60 per cent of alcoholics who achieve at least five years of abstinence do it without using AA.

It's been six years, and Vaillant's plea for humility has either not been heard or already forgotten. In this months' issue of Addiction Professional, columnist Carlton Erickson reports that "fourteen experts" recently met at a "consensus conference" in Rancho Mirage CA to define "recovery," and came up with a definition that includes an implied endorsement for "peer support groups such as AA and practices consistent with the 12 Steps and 12 Traditions."

In other words, judging by Erickson's column, if you're part of the majority that are staying sober without AA you're not considered in recovery. But if you're a chain-smoking Big-Book thumper whose entire social, moral, and intellectual life is wrapped up in AA meetings, then you're a model of recovery. The mind boggles.

The panel's full report, published in the Journal of Substance Abuse Treatment, is considerably more balanced than Erickson's column makes it seem. The report says that "the founders of AA recognized that there were many paths to the same position ... and did not suggest that their specific methods were the only means to attain the overall goal." (Thanks Jason Schwartz for forwarding the full article.) The panel considered but expressly rejected the definition of recovery as "abstinence attained through adherence to 12-step principles."

That's progress. But the plug for AA and the 12 steps is highlighted in the report, and Erickson's column picked up on that highlight, as most hurried readers will.

This endorsement is completely gratuitous. It comes in the absence of any evidence cited in the report showing either (a) superior efficacy of 12-step over other paths in reaching long-term sobriety, or (b) a positive association between long-term participation in 12-step groups and measures of "personal health and citizenship."

The report admits that no validated instrument for measuring "personal health and citizenship" exists. Then what scientific ground is there for making the claim?

The implied beneficial effect of AA participation on "personal health" is indefensible given the notorious prevalence of nicotine addiction among AA members. The report takes note of the nicotine problem, including "significant rates of emphysema, cancer, and other terminal health conditions associated with these products among those otherwise in recovery" (read: in AA). But come to the bottom line, the panel tucked tail between legs and "considered it best to remain silent on tobacco use within the sobriety component of the recovery definition."

The next line is lovely: "It is admitted that there is no clinical justification for this position."

The claim that long-term AA participation enhances "citizenship" is equally dubious. The cited ground for it is the AA homilies for doing service, "giving back." But this "service," to the limited extent people actually do it, is in the nature of recruiting for the AA organization. AA has no outward-directed community service component on the order of the Masons, Shriners, Rotarians, and many other groups. So where does "citizenship" come in?

Trying to come up with a definition of recovery is a laudable project. The panel notes that recovery science (as distinct from addiction science) is a poorly developed field, and that the lack of a validated definition of 'recovery' is a significant obstacle. But when you enter the gates of science, the motto is "lasciare ogni sospetto" -- here drop all hesitation, abandon all fear. So long as recovery scientists keep genuflecting to the sacred cow in the room, little progress and considerable dung is to be expected.

Choice Philosophy Gets a Boost

A new publication by William L. White and Ernest Kurtz gives a boost to the principle that persons in recovery deserve a choice (a LifeRing motto, see the top of the start page of www.unhooked.com). Read about it in the LifeRing Convenor blog, here.

Rays of hope from Recovery Summit

A Recovery Summit under the auspices of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) convened with little fanfare in the winter of 2005, and its report has now been released. Among the "Guiding Principles":

• There are many pathways to recovery. Individuals are unique with specific needs, strengths, goals, health attitudes, behaviors and expectations for recovery. Pathways to recovery are highly personal, and generally involve a redefinition of identity in the face of crisis or a process of progressive change. Furthermore, pathways are often social, grounded in cultural beliefs or traditions and involve informal community resources, which provide support for sobriety. The pathway to recovery may include one or more episodes of psychosocial and/or pharmacological treatment. For some, recovery involves neither treatment nor involvement with mutual aid groups. Recovery is a process of change that permits an individual to make healthy choices and improve the quality of his or her life.
• Recovery is self-directed and empowering. While the pathway to recovery may involve one or more periods of time when activities are directed or guided to a substantial degree by others, recovery is fundamentally a self-directed process. The person in recovery is the “agent of recovery” and has the authority to exercise choices and make decisions based on his or her recovery goals that have an impact on the process. The process of recovery leads individuals toward the highest level of autonomy of which they are capable. Through self-empowerment, individuals become optimistic about life goals.
• Recovery involves a personal recognition of the need for change and transformation. Individuals must accept that a problem exists and be willing to take steps to address it; these steps usually involve seeking help for a substance use disorder. The process of change can involve physical, emotional, intellectual and spiritual aspects of the person’s life.
• Recovery is holistic. Recovery is a process through which one gradually achieves greater balance of mind, body and spirit in relation to other aspects of one’s life, including family, work and community.
• Recovery has cultural dimensions. Each person’s recovery process is unique and impacted by cultural beliefs and traditions. A person’s cultural experience often shapes the recovery path that is right for him or her.
• Recovery exists on a continuum of improved health and wellness. Recovery is not a linear process. It is based on continual growth and improved functioning. It may involve relapse and other setbacks, which are a natural part of the continuum but not inevitable outcomes. Wellness is the result of improved care and balance of mind, body and spirit. It is a product of the recovery process.
• Recovery emerges from hope and gratitude. Individuals in or seeking recovery often gain hope from those who share their search for or experience of recovery. They see that people can and do overcome the obstacles that confront them and they cultivate gratitude for the opportunities that each day of recovery offers.
• Recovery involves a process of healing and self-redefinition. Recovery is a holistic healing process in which one develops a positive and meaningful sense of identity.
• Recovery involves addressing discrimination and transcending shame and stigma. Recovery is a process by which people confront and strive to overcome stigma.
• Recovery is supported by peers and allies. A common denominator in the recovery process is the presence and involvement of people who contribute hope and support and suggest strategies and resources for change. Peers, as well as family members and other allies, form vital support networks for people in recovery. Providing service to others and experiencing mutual healing help create a community of support among those in recovery.
• Recovery involves (re)joining and (re)building a life in the community. Recovery involves a process of building or rebuilding what a person has lost or never had due to his or her condition and its consequences. Recovery involves creating a life within the limitation imposed by that condition. Recovery is building or rebuilding healthy family, social and personal relationships. Those in recovery often achieve improvements in the quality of their life, such as obtaining education, employment and housing. They also increasingly become involved in constructive roles in the community through helping others, productive acts and other contributions.
• Recovery is a reality. It can, will, and does happen.

That's a far better synopsis than one could have expected. Particularly laudable is the recognition, at the top of the list, that "there are many pathways to recovery." Equally enlightened is the acknowledgment that recovery is, at bottom, self-directed and empowering. LifeRing has been making those fundamental points as loud and clear as we are able. It's heartening to hear a gathering of recovery mavens at the national level articulate the same liberating concepts. Even though author William L. White wasn't listed as an author in the report's preface, it sounds a lot like White's New Recovery Movement advocacy. -- Thanks Don Phillips for the tip.

Another Court Rules that AA/NA are Religious

A recent court case ruled that a parolee can sue a parole officer for damages if the parole officer requires the parolee to attend 12-step groups such as Alcoholics Anonymous or Narcotics Anonymous when this violates the parolee's religious or non-religious beliefs.

The case is titled Inouye v. Kemna, issued Sept. 7, 2007. The full text of the opinion is here. The court that issued the decision is the Ninth Circuit of the United States Courts of Appeal. The court's ruling is the law in California, Oregon, Washington, Arizona, Montana, Idaho, Nevada, Alaska, Hawaii, Guam, and the Northern Mariana Islands.

Ricky Inouye was imprisoned in Hawaii after conviction on drug charges, and served his time. As a Buddhist, he objected to participating in 12-step treatment programs because of their religious nature. After his release, he sued his parole officer, Nanamori, for giving him the "choice" of AA/NA meetings or prison.

When that case came to trial in the federal court in Hawaii, Nanamori argued that he, a parole officer, could not have known whether AA/NA are "religious" because the law on that issue was foggy at the time he ordered Inouye to participate (2001). If the issue was unclear, Nanamori was immune from suit. Nanamori won on that issue in the lower federal court in Hawaii. Inouye (or rather his son Zenn, Ricky having meanwhile died) appealed to the Ninth Circuit.

The Ninth Circuit's opinion makes short work of the claim that the law was fuzzy on the religious nature of AA/NA. The court points to virtually identical cases decided before 2001 by the federal courts of appeal for the Seventh Circuit (Illinois, Indiana, Wisconsin) and the Second Circuit (New York, Connecticut, Vermont), in addition to a string of similar cases in lower federal courts and in state courts, all with the same result. The "unanimous conclusion" of these courts was that coercing a person into AA/NA or into AA/NA based treatment programs was unconstitutional because of their religious nature. Because the law on this issue was "uncommonly well settled," Nanamori cannot claim immunity.

Accordingly, the Ninth Circuit sent the case back to the lower federal court in Hawaii to decide how much, if anything, Nanamori has to pay Inouye's estate in monetary damages.

The court's ruling means that criminal justice officers -- or, arguably, any agents of the state, local, or federal government within the bounds of the Ninth Circuit -- can be sued for damages if they ignore a client's religious or anti-religious objections and coerce the person to attend 12-step meetings or 12-step based treatment programs.

What should prisoners, parolees, and criminal justice officers do in response to this ruling?

(1) Prisoners and parolees who have problems with the religious content of 12-step programs should stand up for their beliefs and make their objections heard, loud, clear, early, and on paper. In this case, Ricky Inouye won in part because he wrote letters and filed suit promptly after he was coerced into 12-step programs. He held to his position consistently, and enlisted legal help as soon as possible. Prisoners and parolees need to make it clear both in words and deeds that they earnestly want to remain clean and sober, that they are willing to participate in alcohol and other drug treatment programs and to attend support groups, but that the religious content in the 12-step programs violates their constitutionally protected beliefs and interferes with their recovery. Prisoners and parolees can match these words with actions by demanding referral to non-religious (secular) treatment options, if they exist, and by taking the initiative to organize secular support groups, such as LifeRing, on their own.

(2) Officials in the criminal justice system (and other government officials with coercive powers over addiction offenders) need to offer their clients a choice between religious and secular treatment programs and support groups. The "choice" between AA/NA or prison offends the constitution, and officers who insist on it need to check their professional liability insurance. Government officials can help themselves as well as their clients by sending the message to treatment programs that the programs must embody a secular track along with the 12-step track, or risk losing referrals. Officials need to inform themselves and their clients about the availability of secular support group alternatives, such as LifeRing. Where clients take the initiative to organize such support groups, officials need to be cooperative and provide a level playing field when it comes to rooms, publicity, literature, referrals, and other resources. In an appropriate case, officials may take the lead in initiating secular support groups themselves.

The Ninth Circuit decision ruffles some feathers because it contradicts the belief of many AA/NA members that the 12-step approach is "spiritual not religious." Of course, these words can have many meanings. But as far as the First Amendment of the US Constitution is concerned, the 12-step approach is clearly religious, and the Ninth Circuit only joins a "march of unanimity" of other courts who have come to the same conclusion.

The basic thrust of this line of cases is that the constitutional guarantee of freedom of and from religion extends over the whole of the United States, including the ever-expanding areas enclosed by prison walls. Since such a large proportion of prisoners are there because of drug and/or alcohol abuse, this recent ruling serves as an important refresher. Jails and prisons, notoriously in California, are overcrowded and in deplorable condition. The Ninth Circuit's decision says that the freedom of religious belief or disbelief must not go down the drain along with so many other elements of civilized penal treatment.

Outstanding addiction videocast by Nora Volkow, NIDA director

Many addiction treatment programs and texts feature presentations that attempt to explain addiction with reference to brain structures and chemicals that act as neurotransmitters. I have never heard or read a presentation as able and thorough as the lecture given to physicians Dec. 13 by Nora D. Volkow, M.D., Director of the National Institute on Drug Abuse (NIDA) as part of a Great Teachers series, available as streaming video.

With the tantalizing title, Drug Addiction: Neurobiology of Disrupted Free Will, Volkow tackles head-on one of the central paradoxes of addiction, namely that addiction is a behavior, hence theoretically subject to our free will, and yet it is a behavior which we feel compelled to choose even when we take no pleasure in it and do not want to do it.

Volkow's video lecture runs just over one hour, and if you have any intellectual curiosity about this issue you owe it to yourself to take the time and view it in its entirety. During the first 45 minutes, Volkow reviews territory that will feel familiar to anyone who paid attention to brain research during the 1990s, namely the interplay between addiction and certain receptors for dopamine, notably the low number of D2 receptors in the brains of addicted persons-- processes that occur mainly in the limbic system of the mid-brain. The gist of this is that addicted persons have a reduced anatomical ability to take pleasure from substances that normally provide it.

Then at about minute 48, she launches into the cutting-edge new stuff: research that shows the unmistakable footprint of addiction in the so-called "higher" brain, the forebrain structures where we do our abstract reasoning. The anterior cingulate cortex has the role of interpreting the meaning of external stimuli; it is the spin doctor. In persons who are addicted, this structure is damaged; it has lost its plasticity and can no longer play its normal role of inhibiting urges coming from the limbic system. What emerges from Volkow's lecture is a much more complex, nuanced, and interesting picture of the addicted brain than could have been constructed on the basis of research done ten years ago.

Among the notable points that remained with me:

• Central to the definition of addiction, in Volkow's view, is the fact that addicted persons both want and do not want to use the drug. Volkow is the first prominent researcher to my knowledge to grasp the fact, well known to numerous clinical workers and to addicts themselves, that addicts are internally conflicted about their addiction. The popular notion that addicts are "in denial" about their addiction (that they only want to use and do not also have a conscious contrary volition) is at best a half-truth. Volkow shows with imaging studies why the internal conflict so characteristic of addiction exists.

• Important in overcoming addiction, Volkow says (very briefly) is reinforcement of the addict's own internal inhibitory processes. In other words, positive reinforcement of the addict's inner sober strivings (what LifeRing calls "empowerment of the sober self") is conceptualized as a physiologically grounded recovery strategy.

Although a great improvement over older models in which the frontal cortex was not considered a player, Volkow's enhanced model, based on brain imaging research, still is only a crude approximation. Volkow's model tends to reaffirm Sigmund Freud's basic metaphor of the brain as divided into a pleasure-seeking id (read: limbic system) and an inhibitory superego (= frontal lobes), where addiction can be seen as an excess of the former combined with a deficiency of the latter.

The reality is still more complex. Although current imaging technology may not show it, in addicted persons, the limbic system supplies not only a drive to use the substance, but also a paradoxical drive to get free of it -- a "gut" urge to stop using. And the forebrain is not only a voice for abstinence, but also a paradoxical channel for voices from the culture that promote use of the addictive substance, and an engine of rationalization for addictive use. Consequently, a recovery strategy based only on enhancement of cognitive forebrain functions is likely to (a) also enhance pro-addictive forebrain processes along with anti-addictive ones, and (b) likely to overlook (and perhaps counteract) powerful anti-addictive energies emerging from the limbic system. Effective recovery, in other words, must utilize and coordinate anti-addictive potentials in both the lower and the upper brain; it must be a whole-brain strategy.

Regrettably missing from Volkow's presentation is any reference to the role of the recently discovered "mirror neurons" in shaping social behaviors. It is also worth asking whether Volkow's eminence in brain imaging -- she is one of the world's leading experts in the field -- may not inhibit the search for relevant neurochemicals and processes in other areas of the body, e.g. the stomach. But she only had an hour. These cavils aside, if you want to see a great teacher at work, relaying the state of the art to a medical audience, take an hour and watch the video, here. You will need the widely-available RealPlayer plug-in to view it on your computer, and of course your computer must be able to play sound.

He quit drinking without AA

WILMINGTON, DE: Jerry Dorsman, 59, quit drinking without AA and wrote a book about how to do it. The Delaware News Journal features the author's story in its current online issue. Dorsman, who is now 25 years sober, attended AA but found the spirituality "too narrow and forced," and he saw inadequate attention being paid to stress reduction and nutrition, among other points. Dorsman's book, How to Quit Drinking Without AA, shares his approach. Details.

Choice a Hallmark of Recovery Movement

"One of the recovery movement's hallmarks is empowering people to self-direct their services. This allows people to make their own choices, develop self-esteem and self-confidence, and to become self-determining. This involves people's accountability to live up to their potential. This same level of accountability needs to be present in the structure [of the treatment program]." -- Lori Ashcraft Ph.D. and William A. Anthony Ph.D., "Factoring in Structure -- Recovery needs a solid foundation to take root," in Behavioral Healthcare, Aug. 2006, p. 17.

Client self-direction, making choices, developing self-esteem, self-confidence, and becoming self-determining ... exactly what the Recovery by Choice workbook is built around. And yes, for clients to be able to take this road, the structure of the treatment program must permit it and support it. You won't get this kind of recovery in a treatment program structured around the postulate that clients are too (choose all that apply:) stupid, crazy, dishonest, manipulative, in denial, etc. to ever make intelligent, pro-recovery choices.

Addiction Treatment Behind Bars

The National Institute for Drug Abuse (NIDA) has followed up its groundbreaking "Principles of Effective Drug Abuse Treatment" (1999) with a similar work that addresses issues of treatment behind bars. Titled "Principles of Drug Abuse Treatment for Criminal Justice Populations" and available online, the report is worthwhile reading for anyone concerned with the huge number of people incarcerated in connection with drug and alcohol use.

NIDA's earlier report highlighted the importance of an individualized approach to treatment. Its number one finding was: "No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. "

What holds for addiction treatment on this side of the bars is also true on the inside. The current report says, as point five, "Tailoring services to fit the needs of the individual is an important part of effective drug abuse treatment for criminal justice populations. Individuals differ in terms of age, gender, ethnicity and culture, problem severity, recovery stage, and level of supervision needed. Individuals also respond differently to different treatment approaches and treatment providers." In other words, effective treatment behind bars requires much the same basic respect for individual differences as treatment anywhere else.

Notable also is NIDA's growing recognition of the importance of patient involvement. "Effective drug abuse treatment engages participants in a therapeutic process," the report says, which suggests that getting patients involved in designing and planning their own treatment process promotes therapeutic engagement.

Although NIDA stops short of recommending any specific treatment modality, its research clearly points toward secular and broadly behaviorist approaches. The report says, "In general, drug treatment should address issues of motivation, problemsolving, skill-building for resisting drug use and criminal behavior, the replacement of drug using and criminal activities with constructive nondrug using activities, improved problemsolving, and lessons for understanding the consequences of one’s behavior."

In an accompanying op-ed piece, NIDA director Nora Volkow makes a strong case that treatment for drug-abusing offenders is more effective than incarceration without treatment, and that effective treatment, if it were available, could make a major dent in the crime rate and in the prison population. Source. Needless to add, as incumbent head of a major government department (NIDA is a part of the National Institutes of Health which is part of the Department of Health and Human Services), Volkow is silent on the issue of fading federal spending for treatment, other than faith-based approaches (see earlier blog) -- policies that run directly counter to the research that underlies NIDA's report.

An Effective Choice-Based Treatment Approach

A client-centered recovery program that designs services to fit “clients’ individual experiences, perceptions, and needs” and where staff works with clients “on learning choice-making skills as an essential part of recovery” has scored impressive outcome improvements with a challenging dually-diagnosed populations, says an article in the July issue of Behavioral Healthcare (www.behavioral.net). The choice-based program, called CHANGES, targeted a high-risk population with multiple psychiatric hospitalization histories, including jail time. As a result of the program’s individualized approach, “clients previously considered ‘treatment avoidant’ became treatment receptive.” (p. 36)

This finding will not surprise savvy LifeRing participants (or other readers of the Recovery by Choice workbook). The traditional mental health and substance abuse approaches too often are designed to serve the interests of the providers and payors, rather than clients. Providers frequently assume as rock-bottom truth that clients are incapable of making choices, and therefore must have prefabricated solutions rammed down their throats. Instead of learning to make choices, clients are made to dwell on their moral defects and to affirm their powerlessness to change. Why are people surprised that this kind of approach produces “treatment avoidant” clients and has a dismal outcomes track record?

Millions of taxpayer dollars are wasted every month on treatment programs that are ineffective and in many instances abusive. Lonny Shavelson’s “Hooked” details many of the absurdities in the system. The CHANGES program — embodying some central tenets of the LifeRing philosophy — not only showed significant outcomes improvements, it yielded substantial cost savings. The CHANGES approach deserves consideration and creative emulation by other professionals in the mental health / substance abuse fields.

Letter from a Woman in the UK

We received the following letter at the LifeRing Service Center yesterday. It came via air mail from a woman in the UK. I’ve edited out identifying details. She writes:

“Dear Marty and all at LifeRing,

Thank you for the e‑mail. Also thank you for saying that starting a LifeRing meeting here [in the UK] is providing a valuable service. I am not used to being valued, I am used to being undervalued.

The boss at my place of work has said that if we do the meeting within my working hours we can have the room paid by the fund. I have managed to work out how to order literature from the Internet and the next time I am paid, I will be ordering some things. Meanwhile I am downloading things such as door signs and printing them out.

I hope that this meeting gets underway. Having been in and out of AA/NA for 6 years, I feel a bit uneasy with doing it. However, at the same time I want to. I am scared, you see, to leave AA/NA. I have had it drummed into my head if I do, I will return to active drug use, live and die in my addiction; or if I manage to keep clean, I will have no spirituality and will go insane.

At present, I am seeing a psychologist on the N[ational].H[ealth].S[ervice]. who is aware of my thoughts, feelings and difficulties within the 12 step organisations. I am waiting to go into group therapy, which will last for just over a year.

When I hear of people such as yourself my first thoughts — and please don’t take this personally – are: is that person really clean? Has he/she really got and stayed clean without a 12 step programme? Is this person in a good mind state or are they insane? I can’t help this because of what has been drummed into me. I have been wishing hoping and praying for another way that will work for me — a way that has nothing to do with 12 steps and higher powers (though I have one). . A way where I am supported and befriended by others who are not out to control or abuse me in any way. And I in turn would support them without need to control or abuse.

This LifeRing may be the answer I have been looking for. I believe in the value of one person helping another in support to stay off drugs. But not when one person is out to control or use and abuse the other. And what I have found in 12 step organisations is that those who we have to listen to and stick by usually end up trying to manipulate me for their own ends. Become abusive in different ways. Controlling demanding dominating and putting me down — making me feel as if I am a bad person all the time.

I also find the god concept a bit much at times. I have a belief in god but I do not have a religion. (Or do I? Sometimes I feel like I am in one). And I do not want to talk about god all the time…

The steps also I have went through them but always relapse on the 4th one. ..I did go back once after a short relapse and picked up my 4th step from where I finished it and got it finished and shared that and then went on with the rest of them …then back to the first one to start all over again …I have never got right through all the steps without relapsing. I know that this is a requirement of 12 step organizations, to go through all the steps than start again and keep doing them. I get sick of doing them. It is time consuming and painful.

And I often wonder: if I am (as I hear at meetings) loved as I am unconditionally and accepted as I am, why is it that I have to go through a process of change for the rest of my life? I asked this question and was told because god wants me to. How does one know god wants me to?

Anyway, there are many things I find difficult in 12 step places. And all I have done since I got there is wish for a way out, as I feel trapped. Scared to leave. The same way I have done in domestic violent relationships. I do not know why I am writing to you of these things. I feel I need to explain things. I also feel the need for reassurance that there is actually a way to keep clean and sane without 12 steps and AA/NA meetings. I am sorry if I have done wrong in writing to you. About this. LifeRing seems to be quite well attended in the United States …I hope that this can happen here in Great Britain too. I am not the only person around here who is experiencing difficulties with AA/NA. I hope this will help those people too.

Thank you for all your help [Name withheld].”

Dear _______,

Thank you for your letter. It is heartening to meet a person who has the courage to speak frankly about their issues and who takes practical action to improve their situation. So many people merely complain, without doing anything. If you persevere in your efforts, I feel confident that you will rise above your present difficulties and find a new clarity and happiness.

You write that your first thought about me and other LifeRing people is to doubt that we are really clean and sober. And if we are clean, we must not be sane. I have heard this same doubt from some other 12-step participants over the years, and there are some passages in the Big Book that seem to imply that the 12-step program is the only way to sobriety and sanity.

As to being clean and sober, I can assure you that I have not put alcohol or drugs into my body for the past 13 years and 9 months today, without ever attending an AA or NA meeting. In this I am far from alone. The majority of successful recoveries from alcoholism take place without and outside of AA. The evidence for this finding comes from an unimpeachable source: George Vaillant M.D., professor at Harvard, and a Trustee of Alcoholics Anonymous. In a large, long-term study published as “The Natural History of Alcoholism,” Vaillant found that 60 per cent of alcoholics who achieve five or more years of sobriety did it without AA. You can find this fact in AA’s own Grapevine magazine in the May 2001 issue at p. 36; here is a link to the excerpt. This is, of course, not a criticism of AA. It is merely a reminder that AA does not span the whole universe of recovery. Most of the miracles of redemption from alcoholism occur outside of the 12-step tent. It is important to remember that many people in AA are well aware of this fact and have an open, welcoming attitude toward other recovery approaches.

As to proving that I and other LifeRing people are not insane, that is hard to do. How can one prove one’s own sanity? In truth, I have doubted my sanity more than once. Anyone who undertakes to change the world as it is presently constituted must have moments when the effort seems crazy. On the other hand, when I look at all the people who keep trying the same old recovery experiments over and over again with the same negative result, I wonder who is the crazy one. What’s really insane is to think that the addiction problem is going to get better if we don’t change our approach to it.

You mention that you have done the 12 steps over and over, and always relapsed on the fourth one. I have heard many people share that same experience. It doesn’t surprise me. Focusing on one’s character defects is a depressing, paralyzing occupation, ill calculated to give a person the strength and confidence required to resist cravings and build new, sober connections. In my experience, the path to recovery begins with recognizing the part of ourselves that remains sound and sober, no matter how small and hidden it may be at first. Then the task is to dwell in that place, to connect with that self in others, and so to extend — inch by inch, minute by minute — the dominion of the sober self within our own mind and body. To be sure, in that process we will come face to face with many of our shortcomings, but always in the context of building on and extending our inherent strengths.

You write that many authority figures in your 12-step organizations tried to control you and manipulate you. How is LifeRing different in this regard? It’s well to be aware that there are people everywhere who enjoy controlling and manipulating others, and that the 12-step organizations have no monopoly on that. I have met such people also in LifeRing. The important difference is that — apart from abstinence, our common denominator — LifeRing does not prescribe or suggest a capital-P Program to which all members are expected to conform. We each put together our personal recovery programs, tailor made for who we are and what we need to do. This emphasis on personal recovery programs tends to disarm the control freaks among us. There is no dogma with which to beat someone over the head. Whatever works to keep you clean and sober is a correct program, even though it may be diametrically opposed to the things that work to keep me clean and sober. The diversity of personal recovery programs that result from this emphasis forms a rich pool of experience and wisdom for all of us to draw on.

Again, I want to congratulate you for making the move from contemplation to action. You are definitely not alone in your feelings. Like every pioneer, you may encounter hardships and find yourself a target for stones and arrows. But if you persevere, you will break through to a new reality, and your friends and successors will be thanking you in the years to come.

With best wishes for your success,

Marty N.

Real Medicine Means Honoring Patient Choice

“Here’s a range of treatment options. What do you want to do?” That, according to Bruce Fuchs, the director of the Office of Science Education at the National Institute of Health, is what physicians today are likely to tell the patient. (Newsweek, Jan. 31 2005, p. 9). Presenting patients with a choice of treatment paths and letting the patient choose reflects the growing sense of responsibility that people have for participating in planning their own medical care. “Medicine is less paternalistic than it used to be,” said Dr. Fuchs in another recent interview. A lot of people “recognize they need to be more active participants in their health care.”

For the contemporary physician, giving the patient a choice is nothing less than an ethical obligation. The American Medical Association’s ethics advisor put it this way:

Each individual has the right to determine what medical treatment he or she will receive, including what life-sustaining treatment will be provided for a terminal condition. It is the physician’s responsibility to advocate for the patient’s right to choose any therapy, including alternative or nontraditional treatments, that reasonably may be expected to improve the patient’s quality of life. Source.

Breach of the doctor’s obligation to give the patient a choice of treatment options may constitute actionable negligence. One current text on the law of medical malpractice puts it this way:

In order to obtain the patient’s informed consent, the doctor must tell the patient not only about the alternatives that the doctor recommends, but also about all medically reasonable alternatives that the doctor does not recommend. A doctor does not comply with the duty of informed consent by disclosing only the treatment alternatives that the doctor recommends. Accordingly, the doctor must discuss all medically reasonable courses of treatment, including non-treatment, and the probable risks and outcomes of each alternative. By not discussing these alternatives, the doctor breaches the patient’s right to make an informed choice and effectively makes the choice for the patient. Source.

Giving the patient a range of alternatives and letting the patient choose is not merely a formal legal exercise. It’s good medicine. Behavioral scientists have long known that treatment which the patient chooses tends to work better than the same treatment when the patient does not choose it. The key is that choice enhances motivation. Source. “A fascinating study found that blood donors perceived significantly less discomfort when they were allowed to select the arm from which the blood would be drawn. The lesson is clear: people are happier and more comfortable when they believe they have some control over a process, particularly an uncomfortable one. Often the control handed over is largely symbolic (as in the choice of arm). In other cases, it’s very real: the medical profession has long recognized the value of allowing the patient to make an informed choice about alternative treatments for cancer and heart disease. These are extremely important, high-stakes decisions, and great value is gained by including the patient in the decision. He or she feels less helpless, less hopeless, and more committed to making the process work.” Source.

What does all this have to do with recovery from addiction? About ninety per cent of the current providers of treatment for addiction in the U.S. subscribe to the teaching that addiction is a disease, on a par with diabetes, heart disease, and cancer. But most of those same addiction treatment providers appear unaware of the basic ethical and motivational approach that real physicians today use in the treatment of patients with real diseases.

Real physicians give patients a choice of treatment options, including options that the physician doesn’t personally recommend. Rare is the addiction treatment program where this principle is observed. In most of them, “range of options” means only the choice between the “Big Books” of AA or of NA. Many treatment providers do not know that there are secular treatment and support group options, and when presented with this information, they do not want to hear it. Such counselors are incapable of conducting the kind of informed discussion of pros and cons of different alternatives that is required today in the real treatment of real diseases.

The real medical model of disease treatment requires obtaining the patient’s informed consent. Few and far between are the addiction treatment programs where informed consent is part of the professional vocabulary. Much more common in the addiction treatment business is the view that the addicted patient does not have the capacity to give informed consent, so that the treatment provider not only may, but must make the choice of treatments for the patient. Therefore, when the addiction patient asks about options or declines to follow the provider’s recommendations, the patient is “in denial” and the provider is justified in applying pressure until the patient “surrenders.”

In real medicine, the authoritarian, nonconsensual approach used in many addiction treatment programs today would be considered unethical, unprofessional, and liable to be prosecuted as malpractice. It’s high time that the addiction treatment field caught up with modern medicine and recognized that patients have rights, including the right to a choice of treatments. Giving patients a choice and involving them as participants in their own treatment yields substantially better results in the treatment of diabetes, heart disease, and cancer. Honoring the addicted patient’s choice among treatment alternatives will yield similar improvement in treating the disease of addiction.