Addiction counseling training and scope of practice

[futureapppsy2]

This came up in another thread, and I thought it would be interesting to discuss. In many (most?) states, addiction counseling is an undergraduate-level license with no required training in mental health outside of addiction (at least in my state, where the only requirement re: mental health is that one of their classes should at least touch on other disorders, which can be... pretty minimal). Given the high rate of co-morbidity among people with substance use disorders and the fact that they often can't be differentiated at intake, this seems sort of questionable to me. It seems like counseling should be a masters-level field across the board and that clinicians treating substance use disorders should also have training in treating other, comorbid disorders. I've also seen programs where students were trained solely in the 12 step model, with no exposure to EBP (CBT, ACT, DBT, SFBT, etc).

Thoughts?

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[Therapist4Chnge]

Obviously a bad idea, but they are cheaper and there are enough interested ppl that schools will churn out “graduates” so.....

 

[cara susanna]

John Oliver recently did a segment on his show about the sad state of rehab programs in the US.

 

[AbnormalPsych]

John Oliver recently did a segment on his show about the sad state of rehab programs in the US.

Here you go:

 

[smalltownpsych]

In my mind, us psychologists have done a pretty poor job in this area and have historically alienated people who are involved in recovery from addiction. I could write on this for days and would probably get into arguments with quite a few psychologists who know much less about this than myself so I have learned not to go down that road. At this point it doesn't matter because we have ceded the territory and the government and self-help movements and lesser trained folks will be the ones making the decisions.

One of my research participants had a very poignant story related to this schism between psychology and people in recovery. She had been sober for 20 years and experienced much success in her life but was frustrated with her opposite gender relationships, As she described it, "I had a bad picker." She felt that the 12-step group which had been so beneficial in other ways was not helping her with this issue and her sponsor suggested trying therapy. After much more pain and with much reluctance, she finally went to a psychologist who told her at the end of one session that she had Major Depressive Disorder and needed to take an SSRI. She said that she was scared to take any medication and so she never went back. I asked her what she did about her relationship problems then and she said resignedly that she just went back to the 12 step group.

This is not an isolated story and for me it is an example of a lack of cultural awareness on the part of psychology. This was actually the perspective of my dissertation research was that there is a culture of recovery and that psychology doesn't really grasp that and thus we alienate or pathologize what we don't understand. Not surprising really since we have done that so many times before.

I'll get off my soap box now. 😀

 

[erg923]

This came up in another thread, and I thought it would be interesting to discuss. In many (most?) states, addiction counseling is an undergraduate-level license with no required training in mental health outside of addiction (at least in my state, where the only requirement re: mental health is that one of their classes should at least touch on other disorders, which can be... pretty minimal). Given the high rate of co-morbidity among people with substance use disorders and the fact that they often can't be differentiated at intake, this seems sort of questionable to me. It seems like counseling should be a masters-level field across the board and that clinicians treating substance use disorders should also have training in treating other, comorbid disorders. I've also seen programs where students were trained solely in the 12 step model, with no exposure to EBP (CBT, ACT, DBT, SFBT, etc).

Thoughts?

Comes directly from the 12-step model of peer counseling/guidance/sponsorship. Good rapport most likely, but poor training, poor boundaries, and lots of clinical myth abound.

There was an LCDAC at my last VA. A patient fav. Great rapport, and even some great skills in process groups. Boundaries and empirically derived treatment...not so much. Probably added alot to the milieu within the residential program...but I would hesitate to pick him for longer term work or relapse prevention work.

 

[futureapppsy2]

In my mind, us psychologists have done a pretty poor job in this area and have historically alienated people who are involved in recovery from addiction. I could write on this for days and would probably get into arguments with quite a few psychologists who know much less about this than myself so I have learned not to go down that road. At this point it doesn't matter because we have ceded the territory and the government and self-help movements and lesser trained folks will be the ones making the decisions.

One of my research participants had a very poignant story related to this schism between psychology and people in recovery. She had been sober for 20 years and experienced much success in her life but was frustrated with her opposite gender relationships, As she described it, "I had a bad picker." She felt that the 12-step group which had been so beneficial in other ways was not helping her with this issue and her sponsor suggested trying therapy. After much more pain and with much reluctance, she finally went to a psychologist who told her at the end of one session that she had Major Depressive Disorder and needed to take an SSRI. She said that she was scared to take any medication and so she never went back. I asked her what she did about her relationship problems then and she said resignedly that she just went back to the 12 step group.

This is not an isolated story and for me it is an example of a lack of cultural awareness on the part of psychology. This was actually the perspective of my dissertation research was that there is a culture of recovery and that psychology doesn't really grasp that and thus we alienate or pathologize what we don't understand. Not surprising really since we have done that so many times before.

I'll get off my soap box now. 😀

Thoughts on 12 step programs? I go back and forth, because anecdotally they're very helpful to a lot of people, but we also don't really have empirical evidence on them, so them being positioned as the cornerstone of recovery in a lot of systems makes me somewhat uncomfortable.

 

[erg923]

Thoughts on 12 step programs? I go back and forth, because anecdotally they're very helpful to a lot of people, but we also don't really have empirical evidence on them, so them being positioned as the cornerstone of recovery in a lot of systems makes me somewhat uncomfortable.

Claims are over-hyped. And it's penetrated into the judicial system, which is not good due to comorbidity, misplacement/misdirected care, and the varying degrees and cause of acute substance abuse. Clinical myths are a problem. And, I always cite the the teleological issue that the "disease" cannot be the same thing as the symptom(s) (i.e, the disease of drinking too much-"Alcoholism"- is also the symptom/behavior).

That said, many people need that type of frequency, audience, and guidance to abstain. I don't think professional MH or substance abuse professionals can do it all. Nor can many people afford it.

 

[StellaB]

Sigh... this was my research area. To but it bluntly and succinctly: AA’s effectiveness is generally overstated, most states do not even require any undergraduate schooling at all, even in some states where they are called licensed addiction counselors (eg Utah), almost no education is required and basically no mental health education. Historically, addictions has been totally ignored by medicine and under the realm instead of religion. Who is to blame... well, consider that the average psychiatrist spends 10 hours of residency in training on addictions. Psychology doctorate requires a grand total of 0 hours (although we are all required to take Psych History, because that’s more important?) Substance use disorders are the leading behavioral health cause of death by a mile. But we all wash our hands of specializing in this treatment and lament how bad it is... honestly, it’s depressing. Not to be a huge downer, but however bad you think it is - it’s worse. So many of the recovery homes out there are outright scams or worse.

 

[Justanothergrad]

I'm not aware of any research on AA effectiveness that tackles the issue of dosing. Perhaps I've missed it, but the few outcome studies I've seen have shown it to be poor at best. People who keep going like it, but that's not a majority. I suspect it makes CPT-C dropout look good. Many enjoy support groups and that's fine, but it's not an acceptable treatment in terms of what we would expect of outcomes.

Substance use is generally one of those areas where psychologists have done a very poor job of defending their competence and establishing it as part of 'mental health' treatment. Why this isnt a required area of training (at best) borders on intentionally stupid.

 

[Therapist4Chnge]

I’ve found addictions research and AA/similar to be very disparate, literally speaking different languages. I’ve seen studies that have had AA at or a hair above placebo, but I don’t claim to be an expection in addiction.

 

[PsyDr]

This entire thing is nonsense.

1) Alcoholics Anonymous defines "alcoholism" as a spiritual disorder. Name another recognized psychological disorder which is spiritual. Then show me how to treat spiritual disorders, because I missed exorcism day in grad school.

2) Cochrane noted that AA has never been shown to actually be effective. Internal AA stuff puts the success rate at around 5%. Good idea to train people in a method that has a 5% success rate.

3) Show me data for the idea that the cathartic method works.

4) The self medication hypothesis has no empirical support.

5) Why do people refuse to acknowledge that people do fun things because they are fun?

6) why does the rest of the world approach substance abuse disorders differently?

7) Why ignore the multi-factorial etiologies that are supported by research?

8) The idea to treat more complex people via less trained people is just stupid.

 

[deleted106747]

In my state, for a time, a major health insurance company claimed that psychologists could not treat substance use disorders unless they had that undergraduate level certificate.

 

[erg923]

In my state, for a time, a major health insurance company claimed that psychologists could not treat substance use disorders unless they had that undergraduate level certificate.

Get the **** out of here?! for reaaalz

 

[Sanman]

In my state, for a time, a major health insurance company claimed that psychologists could not treat substance use disorders unless they had that undergraduate level certificate.

One of the few times I would approve of b.s. online diploma mills. Please print my certificate based on (professional) life experience, thanks.

 

[erg923]

This entire thing is nonsense.

1) Alcoholics Anonymous defines "alcoholism" as a spiritual disorder. Name another recognized psychological disorder which is spiritual. Then show me how to treat spiritual disorders, because I missed exorcism day in grad school.

2) Cochrane noted that AA has never been shown to actually be effective. Internal AA stuff puts the success rate at around 5%. Good idea to train people in a method that has a 5% success rate.

3) Show me data for the idea that the cathartic method works.

4) The self medication hypothesis has no empirical support.

5) Why do people refuse to acknowledge that people do fun things because they are fun?

6) why does the rest of the world approach substance abuse disorders differently?

7) Why ignore the multi-factorial etiologies that are supported by research?

8) The idea to treat more complex people via less trained people is just stupid.

If you want to approach it this way, yes. But weight-loss can be achieved multiple ways, right?
Some methods more empirical than others, and certainly some more "healthy" than others. This too is unregulated, and until we can find a way to control human behavior and the dopaminergic reward system, there will be variations no matter what experts have to say about it.

I agree that the "self medication" thing has gone way beyond it empirical backing. I drink because I like the feeling it produces, as would any lab rat. Chemicals are a powerful thing. But it feels better to say I do it because I am unfulfilled/unhappy/traumatized.

 

[PsyDr]

@Psycycle the entire certificate thing is a oooold legislative thing. Long ago, APA had to create a certificate in substance abuse treatment because the laws required someone to have a certificate.

You’ll see that credential in much older psychologists.

 

[PsyDr]

If you want to approach it this way, yes. But weight loss can be achieved multiple ways, right? Some more empirical than others, and certainly some more "healthy" than others. This too is unregulated, and until we can find a way to control human behavior and the dopaminergic reward system, there will be variations no matter what experts have to say about it.

Weight loss can be achieved through heroin or meth use too. Doesn’t mean they are valid treatment for obesity.

 

[Sanman]

Weight loss can be achieved through heroin or meth use too. Doesn’t mean they are valid treatment for obesity.

Yeah, but I bet I could market it as a supplement. Welcome to 'Murica where capitalism rules and data means little. Hence the D.A.R.E. program.

 

[MAClinician]

Get the **** out of here?! for reaaalz

I wonder if that is connected to CMS/Medicare/Medicaid? In my state, agencies/clinics/organizations that treat substance abuse ONLY are licensed by the state department of public health. I believe dual diagnosis treating clinics are licensed by both DPH AND DMH but I’m not 100% sure. Clinics and agencies that treat mental health disorders are licensed by the state department of mental health. I know as a masters level provider, in a DMH licensed mental health agency I could not bill for substance abuse disorder as the primary diagnosis, it had to be MH because the agency was not “substance abuse treatment “ specific. I’m not sure how it affects providers in private practice, at least in my state, and specifically for providers who bill commercial insurance (as they may align with CMS regulations from my understanding)? Just throwing it out there as something to consider, I could be totally wrong!

 

[futureapppsy2]

Yeah, but I bet I could market it as a supplement.

Phen-fen...

I've also seen states and insurers say that only LADCs can treat substance use disorder, despite it being a less rigorous credential than a counseling or psychology license.

 

[deleted106747]

Get the **** out of here?! for reaaalz

Once again, psychology gets the short seat at the table.

One of the few times I would approve of b.s. online diploma mills. Please print my certificate based on (professional) life experience, thanks.

seriously.

@Psycycle the entire certificate thing is a oooold legislative thing. Long ago, APA had to create a certificate in substance abuse treatment because the laws required someone to have a certificate.

You’ll see that credential in much older psychologists.

It's a complete joke... I think it got dealt with, but the insurance company had absolutely no understanding of psychology and its scope of practice. Enough that it would state that an undergraduate with that certificate was more qualified.

 

[cara susanna]

Sigh... this was my research area. To but it bluntly and succinctly: AA’s effectiveness is generally overstated, most states do not even require any undergraduate schooling at all, even in some states where they are called licensed addiction counselors (eg Utah), almost no education is required and basically no mental health education. Historically, addictions has been totally ignored by medicine and under the realm instead of religion. Who is to blame... well, consider that the average psychiatrist spends 10 hours of residency in training on addictions. Psychology doctorate requires a grand total of 0 hours (although we are all required to take Psych History, because that’s more important?) Substance use disorders are the leading behavioral health cause of death by a mile. But we all wash our hands of specializing in this treatment and lament how bad it is... honestly, it’s depressing. Not to be a huge downer, but however bad you think it is - it’s worse. So many of the recovery homes out there are outright scams or worse.

Thanks for sharing your expertise. Is there anything that we can do to change the sad state of affairs?

I work in the VA system, and it seems like we have pretty good addiction treatment here at least. Although, of course it varies across facilities.

 

[smalltownpsych]

This entire thing is nonsense.

1) Alcoholics Anonymous defines "alcoholism" as a spiritual disorder. Name another recognized psychological disorder which is spiritual. Then show me how to treat spiritual disorders, because I missed exorcism day in grad school.

2) Cochrane noted that AA has never been shown to actually be effective. Internal AA stuff puts the success rate at around 5%. Good idea to train people in a method that has a 5% success rate.

3) Show me data for the idea that the cathartic method works.

4) The self medication hypothesis has no empirical support.

5) Why do people refuse to acknowledge that people do fun things because they are fun?

6) why does the rest of the world approach substance abuse disorders differently?

7) Why ignore the multi-factorial etiologies that are supported by research?

8) The idea to treat more complex people via less trained people is just stupid.

Numbers one and two exemplify the problem psychology has with AA. Number one it is a spiritual program, not a treatment program so number two makes sense because only a small percentage of people who attend for a multitude of reasons end up joining hence the 5% stat. I really think it would be more helpful if psychology would stop looking at it as a treatment and being so anti twelve-step because of our inherent anti-religious bias. I really don't care what a person does to support recovery whether it is LDS or AA or christian recovery or joining a knitting circle. My job is to help the patients navigate whatever path they choose and using MI techniques to help them explore what works and what doesn't for them without introducing my own bias.

 

[cara susanna]

I think that AA can be great, but a lot of people hate it and I'm not a big fan of the rigid abstinence-only approach. I wish that there were other options for people that were readily available, like relapse prevention or harm reduction.

 

[AbnormalPsych]

4) The self medication hypothesis has no empirical support.

Could anyone direct me towards some quality readings on this, please? Thanks in advance.

 

[PsyDr]

Could anyone direct me towards some quality readings on this, please? Thanks in advance.

Read the original Khantzian and Duncan articles in 1974. Then Khantzian's later articles where you can pay attention to how he addresses the evidence against his hypothesis. Then read Lembke's 2012 article. Then read Read's 2014 article.

 

[smalltownpsych]

I think that AA can be great, but a lot of people hate it and I'm not a big fan of the rigid abstinence-only approach. I wish that there were other options for people that were readily available, like relapse prevention or harm reduction.

The "rigid abstinence only approach" is the perspective of AA. If that fits for a patient great, if not then help patient look elsewhere. I fail to see why your being a fan or not of their perspective is relevant. It is important to understand that because some people can moderate their use does not mean all people can and people with addiction can be exceptionally good at getting people to align with unhealthy rationalizations. Also, clinicians should ask why this group is so successful and that there are so few other options for community support.

 

[futureapppsy2]

The "rigid abstinence only approach" is the perspective of AA. If that fits for a patient great, if not then help patient look elsewhere. I fail to see why your being a fan or not of their perspective is relevant. It is important to understand that because some people can moderate their use does not mean all people can and people with addiction can be exceptionally good at getting people to align with unhealthy rationalizations. Also, clinicians should ask why this group is so successful and that there are so few other options for community support.

But we don't know if its actually successful or for whom; that's part of the problem.

 

[WisNeuro]

The "rigid abstinence only approach" is the perspective of AA. If that fits for a patient great, if not then help patient look elsewhere. I fail to see why your being a fan or not of their perspective is relevant. It is important to understand that because some people can moderate their use does not mean all people can and people with addiction can be exceptionally good at getting people to align with unhealthy rationalizations. Also, clinicians should ask why this group is so successful and that there are so few other options for community support.

Is it, though? By what metric are you measuring their success?

 

[PsyDr]

@smalltownpsych

It's a psychiatric disorder, listed in the DSM that a group of people are trying to redefine as a spiritual thing and apply a treatment technique with a 5% effectiveness rate.

Patients deserve to be informed, so they can make their own decisions.

It is not successful. AA put it at 5%. ASAM put it at 10%. Cochrane says there's no evidence. People may feel that it is nice. And that may be something to address and respect in patients. But since 1972, patients have had the right to be informed of the ricks and benefits of their treatments.

My mechanic, despite being Greek orthodox, uses his professional skills to fix my cars. He doesn't send me to his priest. I see no reason why I should do anything different.

 

[Pragma]

Read the original Khantzian and Duncan articles in 1974. Then Khantzian's later articles where you can pay attention to how he addresses the evidence against his hypothesis. Then read Lembke's 2012 article. Then read Read's 2014 article.

I wouldn't hang your hat on Read (2014). Tons of methodological problems in that paper.

 

[futureapppsy2]

I wouldn't hang your hat on Read (2014). Tons of methodological problems in that paper.

Citation for that particular paper?

 

[Pragma]

Citation for that particular paper?

I assume that PSYDR meant this one:

Posttraumatic Stress Symptoms and Alcohol Problems: Self Medication or Trait Vulnerability?

 

[PsyDr]

I wouldn't hang your hat on Read (2014). Tons of methodological problems in that paper.

Yeah, I know. The entire area is rife with methodological problems.

Got any citations to support the self medication hypothesis?

 

[smalltownpsych]

Is it, though? By what metric are you measuring their success?

Again, I am not referring to the group as a treatment so when I am referring to success, i am referring to the fact that they are a successful organization by the same metric by which many organizations would be measured. Membership, influence, widespread.

 

[WisNeuro]

Again, I am not referring to the group as a treatment so when I am referring to success, i am referring to the fact that they are a successful organization by the same metric by which many organizations would be measured. Membership, influence, widespread.

That's a pretty low bar to measure success when it comes to something that is utilized in the mental health arena. Especially an organizations whose "success" is partially due to the legally mandated attendance of some of its members.

 

[futureapppsy2]

Again, I am not referring to the group as a treatment so when I am referring to success, i am referring to the fact that they are a successful organization by the same metric by which many organizations would be measured. Membership, influence, widespread.

The idea that the most effective treatment for PTSD is puppy dogs is widespread and popular. Doesn't mean it's true and that we should stop doing CPT/PET and hand out fuzzy puppies in the VA instead.

 

[smalltownpsych]

The idea that the most effective treatment for PTSD is puppy dogs is widespread and popular. Doesn't mean it's true and that we should stop doing CPT/PET and hand out fuzzy puppies in the VA instead.

True, but as I stated, I take the stance that it is not a treatment and should not be viewed as such. That is consistent with my view on puppies too. Just because many people mistakenly view a 12-step program as a treatment and many people view puppies as a treatment doesn't mean we have to too.

That's a pretty low bar to measure success when it comes to something that is utilized in the mental health arena. Especially an organizations whose "success" is partially due to the legally mandated attendance of some of its members.

I agree that it should not be mandated or used as a treatment. When I was in charge of the addiction component of an RTC, we talked about it as a something that some people find 12 step programs helpful and there is some evidence to support that. There is also some evidence that 12-step programs are not beneficial to some people, particularly if they have significant social anxiety or serious mental illness and it is our role to help with that. I have worked with many patients who attest to the benefits they have derived from 12-step attendance and I support them in that the same way that I support patients who attend church services or other community groups that they find useful.

What I find surprising about these threads is how strong the negative reactions appear to be towards something that I have seen help many people. Maybe it comes from something else I have seen in treatment programs. I.e., the overbearing and obnoxious 12-stepper who thinks that they have the answer to everything and that the professionals don't know anything. They also tend to have extremely poor boundaries. I completely agree that they can be a problem and wouldn't want to hire one of them.

 

[erg923]

True, but as I stated, I take the stance that it is not a treatment and should not be viewed as such. That is consistent with my view on puppies too. Just because many people mistakenly view a 12-step program as a treatment and many people view puppies as a treatment doesn't mean we have to too.

I agree that it should not be mandated or used as a treatment. When I was in charge of the addiction component of an RTC, we talked about it as a something that some people find 12 step programs helpful and there is some evidence to support that. There is also some evidence that 12-step programs are not beneficial to some people, particularly if they have significant social anxiety or serious mental illness and it is our role to help with that. I have worked with many patients who attest to the benefits they have derived from 12-step attendance and I support them in that the same way that I support patients who attend church services or other community groups that they find useful.

What I find surprising about these threads is how strong the negative reactions appear to be towards something that I have seen help many people. Maybe it comes from something else I have seen in treatment programs. I.e., the overbearing and obnoxious 12-stepper who thinks that they have the answer to everything and that the professionals don't know anything. They also tend to have extremely poor boundaries. I completely agree that they can be a problem and wouldn't want to hire one of them.

I just think its a strong (maybe too strong?) empirical stance on the issue. No one knows if AA groups are actually the active ingredient in the person's recovery/maintenance of sobriety. All we really have is "because the members say so (and marketing)," which is unreliable, biased, and not empirical if there is no control group for comparison.

To be clear: I'll never discourage it as an adjunct, I just agree that we shouldn't farm it out to a modality that is largely not empirically-based or studied and pretend we can't do any better. Although, with the current rate of substance use disorders in this country, I also don't see how professional MH can handle it all without some degree of reliance on sober support groups and networks?

 

[Therapist4Chnge]

I have worked with many patients who attest to the benefits they have derived from 12-step attendance and I support them in that the same way that I support patients who attend church services or other community groups that they find useful.

The rub is that ppl (in and outside of AA) view AA as treatment and not church/religious/support only; the court system is the biggest offender IMHO. I too have the stance of “if it helps you, great” but AA isn’t something I promote or encourage bc it ISN’T treatment and it’s at BEST 5-10% effective. I don’t support ANY intervention that has such a low success rate.

I also struggle with the many boundary issues and lack of professional insight and lack of oversight....whether it be 13-steppers, hardliners that ANY medication for pain is a no-no, and the ppl who ignore swapping one addiction (alcohol) for another (working out)...as behaviorally it can still be quite unhealthy and detrimental.

Besides the religious slant it offers, I also take issue w. the dogmatic approach, the rejection of harm reduction as an acceptable option, and the premise that an external factor aka a higher power plays a substantial role in success.

 

[WisNeuro]

What I find surprising about these threads is how strong the negative reactions appear to be towards something that I have seen help many people.

A myriad of reasons have been given, both in this thread, and previous. And, I haven't seen anything to compellingly rebut those reasons at this point.

 

[PsyDr]

What I find surprising about these threads is how strong the negative reactions appear to be towards something that I have seen help many people.

There’s a difference between feeling better and getting better.

How does your idea function when we talk about someone who drinks 8 beers a night because it helps them not be an ass to their family?

 

[Pragma]

Yeah, I know. The entire area is rife with methodological problems.

Got any citations to support the self medication hypothesis?

Well, I'm not a big fan of the self-medication hypothesis in general. It usually doesn't hold up and is just a way for patients to experience things in a less stigmatizing way, given how the world is and how people view substance users.

However, I think it holds up in some cases. There are some disorders where it makes sense and there is data to substantiate that. PTSD is the usual example but that disorder is so multifactorial. Some anxiety disorders. I don't think it is reasonable to take a black and white stance about it though as a provider. There are cases where someone uses to deal with a problem, and when the problem is dealt with, the use ceases. I can pull up a couple of longitudinal studies to that effect if you want. My point is, while self-medication is not the issue in most substance use cases (despite how much people want it to be), it very well could be the primary issue some of the time. The papers you are talking about, and the ideology that you already have on tap about personality factors based on prior discussions, have not been anywhere close to being empirically supported to proclaim as truth. So perhaps join me in demanding better science about this topic, and in the vein of Read et al. (2014)'s discussion points, perhaps be open to the idea of multifactorial etiology. It is never black and white with addiction issues. Personality plays a huge role but it doesn't explain everything, and the science behind that notion sucks so far.

 

[Pragma]

Applying RCT framework to something like AA is ridiculous. It is an untrained, peer-led group where some groups function well, others don't, etc. It isn't treatment. It is a support group. How could you even operationalize a success rate for something that uncontrolled? I think it works for some people and for others it does not. There are so many other factors involved. Some people might benefit from sponsorship or by utilizing service opportunities to help others. Some people might benefit from just showing up and getting past that 90 day hurdle of ****ty HPA axis functioning. It isn't a treatment or cure. Some people have made better lives out of it and some people are turned off by it and maybe even had bad experiences due to a ****ty meeting where people said awful stuff that is untrue. It isn't a treatment. Period. Some people do yoga or join a cancer support group or find a friend that helps them get over a hurdle. The point is that the quality of support that you get from other people that have gone through something similar to you have is superior to the quality of support that you get from people who have not. It's a peer thing, not a treatment thing. Treatment is totally separate. Within the addictions field, that has been conflated a lot in the past, but that is changing (slowly). We do need to do a better job as psychologists. Most psychologists I know have no idea how to talk to someone with an addiction issue and have no understanding of the subculture. That is a problem that needs to be fixed. I'd argue for more training standards but that would only be a tiny start.

 

[WisNeuro]

I think the missed point is, all of us know that AA is NOT a treatment. I really don't think anyone is disputing that notion at its heart. The reality of the situation, though, is that AA IS utilized as a treatment in this country. Whether it be the legal, laymen's, or even in many mental health arenas, people view and use it as a treatment. There, just so we can get that out of the way.

 

[cara susanna]

The "rigid abstinence only approach" is the perspective of AA. If that fits for a patient great, if not then help patient look elsewhere. I fail to see why your being a fan or not of their perspective is relevant. It is important to understand that because some people can moderate their use does not mean all people can and people with addiction can be exceptionally good at getting people to align with unhealthy rationalizations. Also, clinicians should ask why this group is so successful and that there are so few other options for community support.

It's not that I'm not a fan of abstinence only approaches ever, it's just that sometimes they aren't a good fit for the patient and can even cause more problems (abstinence violation effect). If a patient wants abstinence, great, but I don't think that we should force it on people through a one-size-fits-all approach and say that it's this or nothing. All I'm saying is that I want more flexibility in what's available for people, and that includes the possibility of the treatment's goal being more tailored to the patient's actual goal.

Edit to add: Obviously, I recognize that some people have too much difficulty controlling their drinking, but that's something I'd like the patient to be able to decide with their treatment team.

 

[Pragma]

I think the missed point is, all of us know that AA is NOT a treatment. I really don't think anyone is disputing that notion at its heart. The reality of the situation, though, is that AA IS utilized as a treatment in this country. Whether it be the legal, laymen's, or even in many mental health arenas, people view and use it as a treatment. There, just so we can get that out of the way.

No, not all of us know that. That's the point. Do you know how many psychologists that I have met that think that it is treatment? Many psychologists don't even understand what it is or what treatment methods are out there for addiction and how they are successfully applied. A lot of them think that Johnson-Model interventions (think the show "Intervention" - terrible thing to do to someone given the evidence) are the best bet. I've seen people from APA-accredited programs do some pretty awful/uninformed things around the concept of addiction (like making their therapy contingent on a patient not relapsing), and then just refer to AA to get "treated" if they don't want to deal with the patient.

I acknowledge that there is a ubiquitous misunderstanding about what AA is within U.S. culture. But don't throw the baby out with the bathwater. Maybe we could do a better job helping patients and people to understand the difference between treatment and more long term "recovery" supports that should be tailored to a person's goals. There's a lot of other types of support groups out there too. Personally, if I am talking with a patient with addiction issues, I usually let them know the pros/cons of 12-step support groups and prepare them for what the culture is like if that is something they are considering trying, and also let them know about alternatives.

I could make similar critiques about evidence-based psychotherapy treatments. Constantly misapplied with awful fidelity, to the point that I am reluctant to ever refer someone to a psychologist that does therapy without thoroughly vetting that person first. The sad thing is, that is SUPPOSED to be treatment, even though in actual practice it appears that it is not most of the time. What are the evidence-based treatment rates at the average VA? Pretty low at the ones I have seen, and I think it is fair to assume that a lot of those are not following protocol.

 

[PsyDr]

Well, I'm not a big fan of the self-medication hypothesis in general. It usually doesn't hold up and is just a way for patients to experience things in a less stigmatizing way...

I am 100% interested in any empirical citations you can provide. Seriously.

Either the “hypothesis” is supported or it’s not. If it’s not, we should do away with it. The convenience of the lie doesn’t make it true.

 

[Pragma]

It's not that I'm not a fan of abstinence only approaches ever, it's just that sometimes they aren't a good fit for the patient and can even cause more problems (abstinence violation effect). If a patient wants abstinence, great, but I don't think that we should force it on people through a one-size-fits-all approach and say that it's this or nothing. All I'm saying is that I want more flexibility in what's available for people, and that includes the possibility of the treatment's goal being more tailored to the patient's actual goal.

Edit to add: Obviously, I recognize that some people have too much difficulty controlling their drinking, but that's something I'd like the patient to be able to decide with their treatment team.

I agree - one of the big issues with 12-step programs as they've been applied has been their impact on the AVE (although that concept doesn't really apply to a lot of folks either). If you check some of the recent reviews of the evidence for Marlatt's model, not every component is exactly evidence-based. That said, it's a good general framework and jives well with other lifestyle modifications that can help get people through the early stages.

But I disagee with your last statement. Not everyone wants a "treatment team" and given how stigmatizing substance use is, as well as how terrible success rates are for treatment, I wouldn't really push any particular intervention or "treatment team" framework on someone. I'm a psychologist and I think that MI and CBT and medications offer some of the best evidence to help a person out, but addiction is very heterogeneous and not very well-understood - otherwise we'd have even more effective treatments by now. There's a huge group of people that just quit on their own that we don't know a lot about. There's people who do it without any form of "treatment" at all and that rely mostly on community supports and lifestyle changes. I just don't have the hubris to think that we psychologists have it all figured out, particularly (think OP) when many psychologists haven't even taken a class on this.