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It's not 1960 anymore

February 17, 2014
by Gerald Shulman
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Gerald Shulman

I began my career as an alcoholism counselor in 1962 in a 28-day, inpatient, 12-Step, disease model alcoholism treatment program. There was no patient assessment of any kind, there was no treatment planning, and treatment consisted of 28-day immersion in the Steps and Principles of Alcoholics Anonymous (AA).

Group therapy consisted of reading and discussing a chapter in the Big Book or listening to a tape recording of someone telling his/her story at an AA meeting. The psychoeducational component consisted of Step lectures or topics such as the disease of alcoholism. What I have just described would not be considered “treatment” by today's standards.

Funny thing, though: It worked, and many patients went on to become the early alcoholism counselors after their own treatment. The fact that this approach was the precipitant for so many people to begin their recovery screams for explanation. If this was not treatment by today's standards, as valuable as it might have been, this phenomenon leads us to take a closer look at the patients back then.

A more homogeneous group

The demographic of patients 50 years ago was remarkably different from that of today's patients. They were mainly white, male and middle-aged, and used alcohol almost exclusively. For the few people who might have been using other drugs, these were prescribed medications such as barbiturates and early benzodiazepines. If an individual used illegal drugs such as heroin, he simply was not admitted to this type of program.

At that time, alcoholism and illicit drug addiction were considered two totally different disorders, and the treatment approaches were very different (for example, people in drug therapeutic communities could earn “drinking privileges”). Treatment for the two disorders was provided in separate facilities.

People with co-occurring mental health disorders were usually referred to a mental health provider, and if they were somehow admitted to alcoholism treatment they were routinely taken off all psychiatric medications. If they had criminal justice problems, they went to prison or jail instead of treatment.

Most patients were employed, often in higher-level positions or professions. If they were not employed, they most likely had lost their employment because of their drinking. Very few had not graduated from high school. Many were college graduates or had postgraduate degrees. If they were not living in an intact family, the most common reason was loss of their family due to their drinking.

I used to say, “If you wring a drunk out damp dry, you have a functional drunk!” This was accurate in that these individuals had been functional and their current dysfunction resulted directly from their alcoholism. They were truly “rehabilitatable.”

Moving ahead to today's patients, we find that many, particularly in the public sector, are not rehabilitatable but only “habilitatable.” This means learning coping and living skills for the first time, as opposed to removing the barriers (the alcoholic's drinking) to coping. And for so many of them, trauma has provided the seedbed for their addiction.

So what we have is a mismatch between yesterday's treatment and today's patients. Please understand that the old psychosocial, 12-Step, disease model treatment is not irrelevant today; rather, it is insufficient by itself to respond to the needs of today's patients.

Three-legged stool

What will it take to enhance the likelihood of successful recovery for today's patients? Relying on my 50 years of experience as a clinician, clinical supervisor, administrator, trainer and consultant, I have arrived at the conclusion that recovery for many is supported by a three-legged stool.

The seat of the stool represents recovery and the three legs represent psychosocial treatment, recovery support services (including case management), and pharmacotherapy or medication-assisted treatment.

Psychosocial treatment incorporates the 12-Step, disease model approach but is broadened by the addition of trauma care and other evidence-based treatments such as motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), hypnotherapy, neurolinguistic programming (NLP) and eye movement desensitization and reprocessing (EMDR). It also might include the Community Reinforcement Approach (CRA), family and couples therapy and assertive community treatment (ACT), depending on patients' clinical and demographic presentations.

Still, psychosocial treatment alone is inadequate to bring about recovery for many addicts. The fallacy is that while we might consider addiction to be a chronic, relapsing brain disease, we have been treating not the whole brain, but only a portion of it—the cerebral cortex, the thinking, reasoning, cognitive part of the brain. We have done this with individual and group therapies, reading and writing assignments, and psychoeducational presentations. What we have not done is treat the limbic system, the part of the brain responsible for drives such as hunger, thirst, sex, and drug craving.

It is very difficult for patients sitting in group to be able to focus on treatment when they are craving and all they can think about is how and when they can get their next drink or drug. Fortunately, there are medications that can lessen those cravings, with direct anti-craving effects (antagonist treatment) or through substitution of another drug for their drug of choice (agonist treatment). Yet in spite of extensive research pointing to medications' efficacy, there is still much resistance among many providers to use them at all, much less embrace them. This cries out for an explanation.