Motivating Motivation

[Originally posted on hellowellness.in on Oct. 29 2010]

Everyone concerned with addiction recovery knows the importance of motivation.  As Darlene, a heroin addict portrayed in Dr. Lonny Shavelson’s wonderful book Hooked, tells her psychiatrist, “You can talk at an addict until you’re blue in the face, but if they don’t want to get clean, they’ll tell you to f**k off.”  Almost every treatment modality works if the patient is motivated;  nothing works at all if the patient isn’t.  

A group of counselors and researchers grouped under the umbrella label of Motivational Interviewing has been working for a couple of decades on cracking the secret of motivation, and they’ve shown a series of positive results.  Their latest success comes in the highly challenging area of weight loss.  

Weight control is probably more difficult than getting free of alcohol and other addictive drugs because abstinence is not an option.  You can very well live without alcohol and other addictive drugs, and abstinence creates a bright line that can guide your every step.  But you can’t live without food, and threading your way through the maze of conflicting nutritional advisers can defeat the most dedicated mind.  

Doctors, the researchers noted, frequently talk to their patients about weight.  But how the doctor talks to the patient makes a crucial difference.

Doctors who assumed the traditional role of authority, who used a confrontational approach, who appeared to judge the patient, or who pushed unasked-for advice, had no positive effect whatsoever on patients’ motivation, the study found.  Their weight was almost exactly the same as patients whose doctors never raised the issue with them.  In other words, doctors who used the conventional authoritative approach were wasting their time.  

By contrast, doctors who used an approach based on Motivational Interviewing fired up their patients’ motivation, and such patients registered a weight loss of 3.5 pounds at follow-up three months later.

A basic principle of Motivational Interviewing is that real change in feeling and behavior can only come from the patient, not from the doctor.  The key to success, therefore is to elicit and to support the patient’s own inner desire to change.  The doctor accepts the patient’s shortcomings without judgment.  The patient’s successes, no matter how small, merit recognition and praise.  The physician does not pose as an authority, but as an ally and collaborator.  

Dr. Kathryn Pollak, Ph.D. of Duke University, lead author of the study, commented that the physician’s traditional role as expert dispenser of pills or advice has its utility in treating acute distress, but is ineffective in changing patients’ attitudes and motivating long-term, sustainable behavior change.  

“When it comes to behavior change, the patient is the expert, not the doctor.  The whole point is to help the patient solve the problem himself.  Doctors have to see the difference between behavioral counseling and the rest of their job,”  Dr. Pollak said.

The study appears in the October issue of the Journal of Preventive Medicine.

LifeRing groups are abstinence-based, but the Motivational Interviewing approach is deeply congruent with the LifeRing pathway to recovery from alcohol and other drug addiction.  The strategic pathway to recovery is empowerment of the sober self, which means recognition and support of the recovering person’s own inner desire to change.  I’ve written about this approach in detail in my book Empowering Your Sober Self, for those who wish to know more about it.

Pain Relief Without Addiction: Walking the Tightrope

[Originally published on hellowellness.in on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

The Drive to Thrive

[Originally published Sept. 4 2010 on hellowellness.in]

The great majority of young people who experience the death of a parent, divorce, emotional or physical abuse, substance abuse, mental illness, developmental disabilities, and similar ordeals end up OK.  They recover, form healthy relationships, have good marriages, and become productive citizens. That, at least, is the finding of numerous studies in a diversity of cultures, summarized by the researcher Bonnie Benard at the outset of her book on Resiliency.  

I shouldn’t have been surprised.  I lost my father before I was born, I survived bombing raids, childhood malnutrition and diseases, numerous changes of home, several addictions, and I’m OK.  And I’m not alone.  I know lots of people with worse experiences who survived -- we all do.  

How did we manage?  What is the secret of our marvelous ability to spring back from adversity?  

Resiliency, writes the author, is a creature with four legs.  First, the resilient person is able to win approval from others.  Perhaps only from one other, but that is enough.  Second, the resilient person is resourceful, inventive, able to solve problems, to make and execute plans, and adapt to changed circumstances.  Third, the resilient person displays autonomy.  They are goats rather than sheep.  Finally, the resilient person has a sense of purpose.  It may be a spiritual or secular purpose, but it gives them a sense of orientation in space and time, a reason for being alive.

With this in mind, I reflected back on my experience in overcoming my addictions to alcohol and other drugs, and I began to understand more deeply how I succeeded in freeing myself from these shackles.

In my recovery from addiction, I participated in a support group network that systematically provides its members with social approval, the first leg of resiliency.  In these groups, the basic principle is that all participants have a sound and healthy core, which we call the Sober Self, and that our work consists of affirming and empowering that positive quality within ourselves.  In the jargon of social science, our groups are “strength-based.”  

I was surprised, early on, that nobody in these groups wagged a finger at me and told me what I had to do.  On the contrary, I was expected to figure it out for myself.  I was advised to think, to marshal my inner resources, to be inventive, to solve my particular problems, to make a personal recovery plan, and to adapt my personality to clean and sober living.  Motivated in this way, I developed the second leg of resiliency.  

My group work always aimed to enhance my power to survive as a clean and sober person outside the group.  I came to believe that the group was a useful support, and I enjoyed -- and still enjoy -- the fellowship and good humor that prevails within the circle.  But no one ever tried to make me dependent on the group, to substitute group addiction for substance addiction.  On the contrary, my group experience was and is a school for personal autonomy, the third pillar of resiliency.

Finally, my participation in my support group network restored to my mind a sense of purpose, mislaid somewhere during the depths of my addiction.  I began to feel that I was useful in some modest way to others who had been similarly lost.  I developed connections with other people, the key ingredient of a sense that one’s life has meaning.  

Thanks to Benard’s book, the secret of my recovery from addictions -- a journey which I thought impossible before I began it -- is no longer so mysterious. Benard writes that the qualities that make up resiliency are hardwired into the human makeup, and all that is required to foster more recoveries is to remove the barriers and enhance the protective factors for our innate drive to thrive.

Exercise for the Choice Muscle

[Originally posted Sept. 4 2010 on hellowellness.in]

My friend Alex saw the Light.  He made the Big Decision not to drink any more.  Ever.  On the way home from church, he passed his favorite liquor store.  He made the small decision to turn into its parking lot. 

My friend Sandy had had it with drugs.  While walking in the park, she made the Big Decision to get clean.  At the edge of the park, she could turn left or right.  She decided to turn left, where she usually ran into her dealer.

Moral:  the Big Decisions need the support of the small decisions, or they crash.  The old alcoholic support groups came close to this lesson with the slogan, “One day at a time.”  But at the beginning, it’s more like one minute at a time, or even one second.  What matters is the choices we make while the clock ticks.  The small decisions.  

Addiction is the enemy of decision-making.  Addiction is dictatorial.  As we saw in my previous blog entry, chronic use of addictive substances impairs the brain’s synaptic plasticity.  Major brain circuits become rigid, sclerotic, like arthritic joints.  Our decision-making muscles become enfeebled. 

De-addiction, it follows, must exercise the choice circuits in the brain.  We need to give the prefrontal cortex, the center of executive functionality that makes our brains anatomically human, a steady progression of challenges to think, weigh, and choose.  Repeating slogans and formulas or reciting memorized life stories won’t do a thing for our decision-making organ.  Only persistent decision-making exercise will strengthen its capacity. 

Let’s begin with the body.  Do I have externally visible marks of my substance use?  Do I have red veins in my face, drug stains on my fingers, receding gums, puncture marks, etc.?  Do I have hidden body damage, such as liver damage, heart problems, malnutrition, etc?  Is my diet what it should be?  Am I getting the exercise I need?  Are my teeth properly cared for?  Is my mental state satisfactory?  And if not, what exactly should I do about all of that?  What is my plan? 

Let’s consider my immediate surroundings.  Are there drugs (including alcohol) in my home?  In my car?  At school or work?  Do I have objects that trigger thoughts of drinking/using in my environment?  Where are the ‘hot spots’ of danger in my daily travels, and how can I avoid them?  Make a map!
 

How do I spend my time?  What about the people with whom I associate?  What is the condition of my emotional life?  Is my lifestyle helpful to my recovery, or not?  What aspects of my personal history are assets to my new life, and what aspects drag me back?  Am I prepared to handle the many mixed messages about drinking/using in my culture?  Is my treatment and support group program optimum for my needs?  Am I prepared to handle near-relapse situations?  Make a plan! 

Our LifeRing meetings focus on the small decisions that people make from day to day.  In my years of attending LifeRing meetings, I’ve heard literally thousands of detailed, particular questions that have challenged all kinds of people in recovery.  I’ve distilled and organized these questions into nine major topic areas and put them into a workbook, Recovery by Choice.  It’s an exercise book for the prefrontal cortex.  It’s like a body-building gym on paper.  Your sober self enters as a 90-lb weakling, and comes out as buff as Aniruddha.  

[The reference is to Aniruddha Bose, a founder of hellowellness.in]

Ireland Leads the Way

A number of people have told me that my new book, Empowering Your Sober Self, would make a good classroom text in addiction recovery, but no one has done it  -- until now.  The pioneer is Arthur McCullough, BSc, BSSc, MA, at the Queen's University in Belfast.  The University has announced a new class beginning April 28, as follows:

Empowering People Against Addictions [OLE1097]

Arthur McCullough, BSc, BSSc, MA 5 weekly sessions on Wednesdays 7.00 pm to 9.00 pm, starting 28 April This course is about how and why people get into addictions, and about how they can get out of them. It covers major areas of addiction such as alcohol, drugs, gambling, sex; and related ones, such as isolation, suicide, physical and mental illness. Discussions involve perspectives in science, culture and society, and will focus on the recovery model. Recommended Textbook: Empowering your Sober Self, Martin Nicolaus, (Jossey-Bass. A Wiley Imprint). 5 CATS Points (Level 1) (concession rate £19.00) Full Price: £30.00

Here's the link if you want to sign up.  I'm grateful to Dennis S., LifeRing area convenor for Ireland, for spotting this web item and alerting me to it.

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?  

Congratulations to Barack Obama

As a college student at Wesleyan in '61 (or was it '62?) I joined with other white students to team with groups of black students from Howard University in an effort to integrate lunch counters in Glen Burnie, a suburb of Baltimore.  In some places we sat indefinitely without being served; in one, we were served coffee with salt in it; at another they locked the doors as we approached.  When we picketed the segregated local movie theatre, a mob of white men surrounded us as sheriffs watched.  A providential cloudburst scattered the crowd and allowed us to escape.  

On the night of election day in 1964, I arrived at the civil rights movement headquarters in Jackson, Mississippi, to begin a few months of volunteer work.  Nearly everyone was glued to the TV set to see whether the Democratic Party would seat the elected black delegates running under the banner of the Freedom Democratic Party.  The answer was, no.  

These and other memories came upwelling as I watched the inauguration of Barack Obama.   The party that wouldn't seat elected black delegates had nominated a black man for president.  A man whose father would not have been served at DC area restaurants 60 years ago was taking the oath of office.   Indeed, there has been some changes.

This morning's San Francisco Chronicle editorializes that Obama's new approach is "grounded in sobriety and hard work."  The "sobriety" that's meant here is, I assume, the metaphorical kind -- a pragmatic, realistic attitude -- and not the literal kind, meaning abstinence from alcoholic drink.  Yet there's a connection to reflect on, here.  

For me, personally, my time of active engagement in the civil rights movement was largely a time when my alcoholism (acquired in my freshman year in college) was in remission.  Engagement in life-changing work was hugely more interesting than drink.  My drinking habit only bloomed large during the years of reaction that followed, when it seemed that everything we had done was being undone.  Pessimism, despair, lack of hope were the atmosphere in which this illness flourished.  And I'm not the only one.  Is it an accident that the drug problem grew larger in rough proportion as conditions for the poor and middle class in America stagnated and deteriorated?  

Barack Obama's own history with alcohol and other drugs offers a refreshing contrast to that of his predecessor in office.  Obama has freely and openly admitted experimenting with drugs as a youth, but then stopped; he is trying to quit, or has quit, smoking.  What a contrast to the history of "W," whose claimed mid-life alcohol salvation story is widely believed to be a sham that covered up more than it revealed, notably a long history of cocaine use, some say.  

I've not yet seen anything in the way of Obama's statements so far that gives a clue to his specific policies on alcoholism and other addictions.  The federal government has many levers to pull and many dollars to spend in this area.  On general principles, I assume that Obama will support the recent extension of parity in the treatment of mental health and addiction treatment.  I assume that the federal agencies in this area will continue to be funded.  

The open questions in my mind are (a)  War on Drugs, and (b) Federal excise taxes on spirits and tobacco.  We need "change we can believe in" in the "war on drugs," a criminal exercise in hypocrisy and racial/economic persecution that is long overdue for radical reform.  An even more telling mark of Obama's mettle will be whether he supports Congressional action to raise the excise taxes on liquor and tobacco.  Public health advocates have long maintained that raising these taxes is the single most effective measure to reduce the social impact of these two most murderous addictive drugs.  Needless to say, the pillars of corporate greed stand deeply dug in on this issue.

The largest opening in the clouds under this new administration will be in the area of improving living standards and reducing inequities for the poor and middle class.  If the real and emotional environment of ordinary people in this country becomes infused with progress and hope, the problems of alcohol and other drugs will recede as if of their own accord.  It will take some time, but if the new administration succeeds in this largest and most difficult of goals, we will, in fact, see a new era of "sobriety" in both senses of the word.

Congratulations to President Barack Obama, and best wishes for the future.

P.S.  To date, the White House Office of National Drug Control Policy remains under an interim head, Patrick Ward, a Bush appointee who has held the post a bit over a year.  Obama's choice of Rep. Jim Ramstad to become the new Drug Czar has run into heavy fire for Ramstad's ties to abusive "faith-based" programs, his policy positions on prevention, and his ties to a massive investor fraud.  Read Maia Szalavitz's blog blast and the Drug Policy Alliance editorial.  Ramstad is not change, he's MOTSOS.  

End Stage

Is nothing sacred? Michael Shermer, Scientific American's Skeptic columnist, reports in the November issue that one of the icons of psychology, the five stages of grief, has been debunked.

Launched by Elizabeth Kubler-Ross in her book On Death and Dying (1969), the model of denial-anger-bargaining-depression-acceptance is one of the most widely known paradigms in modern psychology. But, according to Shermer's sources, there appears to be no evidence that most people most of the time go through most of those stages in that order, or any other order.

The five stages of grief, along with similar "stage" theories, Shermer says, satisfy people's craving for simplicity and predictability. Unfortunately, the scientific basis for them is just not there. And they can also impose feelings of guilt and shame on people who are not feeling what they think they should. And, in today's world, people who follow the simple "stages" narrative are the exception, while diversity and individual variation are the rule.

Good grief! What's next? Are we going to learn that there is no evidence that most people recovering from addiction go through a certain well known set of steps?

Spirituality strikes out

Two controlled trials of the effect of spirituality on addiction recovery showed no improvement for the patients given spiritual guidance as part of the usual treatment regimen, either in their addiction recovery or in their spiritual practices.  In fact, in one trial, the patients provided with spiritual guidance made less progress in overcoming depression and anxiety than the patients not given spiritual treatment.

Details are in the Journal of Substance Abuse Treatment, July 25 2008.  The abstract is here.  Thanks to David Kaiser Ph.D. for flagging the item.  

Confrontation Therapy, R.I.P.

Two of my favorite scholars have combined to write a powerhouse of an article that everyone interested in addiction treatment will want to read. William R. Miller, co-author of the Handbook of Alcoholism Treatment Approaches (reviewed here), and William L. White, author of the monumental history Slaying the Dragon (reviewed here), have written what hopefully will be an obituary for an era, entitled "Confrontation in Addiction Treatment." It's in Counselor Magazine. Here are a few snippets from this substantial, strongly researched and comprehensive treatment:

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

....

Early claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).

...

There never has been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Quite to the contrary, research on virtually any measure reflects wide diversity of personal characteristics among people with addictions, who are about as diverse as the general population, or as snowflakes. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes (Donovan, Hague & O’Leary, 1975).

...

Reviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.

If you've ever been exposed to confrontation therapy, or have a confrontational counselor now, by all means read this article, sure to be reprinted in textbooks and to become a classic.

If there's one defect in it, it's in glossing over the confrontational therapy element in AA itself. Dr. Harry Tiebout, whose psychiatric theorizing framed the confrontational approach, was hugely influential on Bill Wilson, and he was not alone. Dr. Silkworth echoed the theme, with his advice to Wilson to "give them the medical business, and give it to them hard." The "medical business" meant to convince the alcoholic that he was suffering from an incurable fatal illness. This revelation was designed to attack and to "shatter" the alcoholic's defenses, to "deflate" his ego, and render him hopelessly dependent on his "physician." The very first clause of step one, the foundation of the whole edifice, "powerless over alcohol," expresses a confrontational strategy, as thousands of counselors have found out in practice. To be fair, this is not the only element in AA; there are other strands that tend to counterbalance it. But the article is certainly wrong in claiming, as it does, that there is no attack therapy strand in AA at all. -- This cavil aside, the article is a masterful piece of work, by two giants in the field. Highly recommended.

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.

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.