Michael Pond, MSW, RN Private therapy practitioner in Vancouver, BC specializing in addiction treatment. Author of Wasted: An Alcoholic Therapist’s Fight for Recovery in a Flawed Treatment System.Michael Pond has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: You have seen recovery from two perspectives—a person in recovery and a person who treats substance use disorders. What does it mean to be in recovery?
Mr. Pond: For many people, the word “recovery” means being in AA or another 12-step program where the goal is to stay abstinent. It’s a culture of mutual support where people help and assist each other toward the goal of sobriety.
CATR: Is recovery a form of treatment?
Mr. Pond: No, it’s not the same. I’ve asked people who are involved in 12-step organizations, “What are you if you’re not treatment?” They’ve told me, “We are a movement, a program, an organization, and a way of living, but we are not treatment.”
CATR: Interesting. How does treatment fit with the recovery model?
Mr. Pond: It’s a complicated relationship. Many people feel 12-step groups help them, and that’s fine. But when recovery principles are conflated with treatment, they can become a barrier to accessing evidence-based, harm-reduction approaches.
CATR: In what way?
Mr. Pond: In my experience, 80%–90% of treatment programs are based on the 12-step recovery model. I appreciate how important personal experience can be, but often these programs are unlicensed, unregulated, and run by people whose only training is that they are in recovery themselves. For some programs, insistence on delivering the steps is a cheap alternative to spending the money on evidence-based therapies and medical treatments.
CATR: It sounds like you aren’t impressed with some aspects of the recovery model. What is the evidence that 12-step recovery programs work?
Mr. Pond: Well, AA’s own membership survey reports the average length of member sobriety is almost 10 years (http://www.aa.org/assets/en_US/p-48_membershipsurvey.pdf). This may sound impressive, but it’s not really scientific. Was AA the reason people become abstinent, or would they have entered spontaneous remission anyway? There’s one RCT that showed outpatients randomized to intensive 12-step referral had both higher group attendance and better substance abuse outcomes at 6 months than those not referred (Timko C et al, Addiction 2006;101(5):678–688). On the other hand, the Cochrane Collaborative published a meta-analysis the same year and could not unequivocally conclude AA was successful at all (Ferri M et al, Cochrane Database Syst Rev 2006;19(3):CD005032).
CATR: Do you find any other problems with the recovery model?
Mr. Pond: Yes. In many recovery programs, relapse is perceived as a failure. There are two problems with this. The first is that people with addiction already carry around a truckload of shame, and they don’t need any more. For example, when my addiction was at its worst, I visited the emergency department more than 30 times in four years. Every time I walked out of there, my head was hanging in shame. The last thing I needed to hear—from myself or anyone else—was that I’d failed again. Seeing relapse as a failure can actually lead to more relapse. Alan Marlatt, the father of relapse prevention, called this the abstinence violation effect. Patients think to themselves, “I violated abstinence; I’m nothing but a drunk and a loser, so I might as well just keep drinking” (Marlatt A and Gordon J, eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985).
CATR: What other problems do you see?
Mr. Pond: A key concern is the high level of comorbidity between substance use and other mental health disorders. Support groups are wonderful and can reduce problematic substance use, but they can’t diagnose or treat a comorbid mental health condition. In my own experience in these groups, I’ve observed many individuals suffering from anxiety and depression, bipolar disorder, and schizophrenia. For example, I once spent three weeks in jail for a drunk driving offense. It was clear many of my fellow inmates had mental health problems, but the only “treatment” they got was a weekly AA meeting. We can’t expect 12-step meetings to take the place of mental health treatment, but in some settings that’s all people get.
CATR: Can you expand on the difference between an abstinence-based model and a harm reduction model?
Mr. Pond: Well, an abstinence-based model is just that: You start the recovery process with the goal of being abstinent. It’s different with harm reduction, where what we are looking for is any positive change. For example, say I’m working with a patient who is averaging 20–30 bottles of beer a day. He’s been trying for years to get sober through AA and other abstinence-based approaches, and he just hasn’t been able to do it. Once he arrives in my office for the first time, he feels like a total failure—and by traditional recovery model standards, he is. A patient like this is unlikely to succeed unless we can change that mindset.
CATR: I see. How do you go about changing it?
Mr. Pond: In my practice, I might say to this patient, “We are going to reframe this whole thing. We’re going to start by simply tracking how much you’re drinking, and graphing the results over time. Then we’re going to explore different types of evidence-based treatments using a biopsychosocial model. I’m going to do cognitive behavioral therapy with you, and we’re going to look at medications that might help you with cravings and withdrawal, like naltrexone and acamprosate. When even the tiniest progress is made, I’ll say, ‘Look at this graph! You’ve been drinking less.’ ” Every small victory helps the patient build a sense of success, self-efficacy, and empowerment. We need to get the message out: There are now many more options in the toolkit to treat substance use. We want patients to get well; it doesn’t matter what pathway they take to get there.
CATR: It sounds like the harm reduction model takes more of a “glass half-full” approach. What are some other techniques you use for harm reduction?
Mr. Pond: I use a lot of motivational interviewing. I also rely on the CRAFT model; this stands for Community Reinforcement and Family Training and was first developed by Dr. Robert Meyers out of the University of New Mexico. CRAFT involves operant conditioning to decrease positive reinforcement for substance use and increase positive reinforcement for sobriety (Meyers RJ, Alcohol Res Health 2011;33(4):380–388). As you might imagine, this involves working with family members of substance users and teaching them strategies about how to behave differently with the substance users in their lives. After several family sessions, substance users who started out reluctant to engage are often willing to engage voluntarily. It’s an approach that’s based on kindness and compassion rather than confrontation and coercion. (Ed note: The upcoming June/July issue of CATR will also cover the CRAFT model.)
CATR: You’ve talked about how recovery principles can cause problems with treatment. Does treatment cause problems with recovery?
Mr. Pond: It can, when the treatment is not truly evidence-based. For example, getting doctors to prescribe medications like naltrexone or acamprosate can be a struggle. In my experience, many doctors “prescribe” AA without even considering evidence-based medical treatments. The National Center on Addiction and Substance Abuse found that only 1 in 10 patients with substance use disorder receive any kind of treatment, and even fewer receive evidence-based treatment. This is compared with 70% or 80% of patients with high blood pressure or diabetes who do receive treatment for those conditions (https://tinyurl.com/jwgz325).
CATR: How do you help your patients in recovery access evidence-based treatments if they need them?
Mr. Pond: The first step in AA is to admit you’re powerless, but I prefer to build a partnership with my patients and empower them. That includes letting them know there are medical options, and encouraging them to give those options a try. My colleagues and I developed an information and resource postcard that patients can give to doctors, nurses, and other professionals that links to information about medical treatment. I tell them to hand it to the doctor and say, “Have a look at this—if you go to this website, you are going to find medications that can help me. I want to find out if any are appropriate for me to try.” (See http://addictionthenextstep.com/resources for more information.)
CATR: What other advice would you give psychiatrists?
Mr. Pond: I once spent two weeks in intensive care, after I contracted pneumonia from aspirating vomit while I was intoxicated. A nurse quietly looked at me and said, “You know you brought this on yourself, don’t you?” This didn’t help. Health professionals need to treat patients with substance use disorders with compassion—just like they treat everything else.