Stop Blaming the Client for the Failure of the Treatment

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Stop Blaming the Client for the Failure of the Treatment

By Thaddeus Camlin 11/10/16

Instilling hope fosters a mindset of success. What we expect has a huge impact on the outcome we experience.

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A snake eating its tail, ouroboros
It's not always an eternal life-and-death struggle.

There is a commonly accepted idea that addiction is a lifelong struggle that most fail to overcome. The current opioid epidemic and the media coverage of celebrities whose downfalls are fueled by substance use perpetuate the idea that most people with substance use disorders are likely to fail in recovery. But it’s more common than most people realize for people who battle an addiction to eventually obtain a stable recovery. In part, it depends on how one defines the term. Dr. Thaddeus Camlin spells out the case for addiction being a disorder that is commonly conquered…Richard Juman, PsyD

Many lies taint the integrity of the recovery industry. One of the most insidious of these lies is that most people in recovery fail. This article will challenge the lie that most people fail in recovery on three fronts: the evidence of success, the failure of treatment, and the common but misinformed criteria for success. This article will conclude by offering some evidence-based options to reinforce its primary objectives: to highlight how the recovery industry often fails its customers, and to honor the resilience of those who struggle with and often overcome problematic patterns of substance use.

The evidence of success in recovery is overwhelming. I often hear people toss around arbitrary and unfounded statistics in recovery like, “only 10% of people succeed,” and that deviations from perfect abstinence inevitably lead to “jails, institutions, and death.” The bad news is that “professionals” sometimes contribute to the spread of these unhelpful lies. The good news is that the lie that most people in recovery fail is unequivocally false. 

People often say that numbers don’t lie. The recovery numbers tell a truth that stands in stark contrast to the idea that most people in recovery fail. For example, 99.2% of people achieve lifetime remission from a cocaine use disorder, 97.2% from a cannabis use disorder, and 90.6% from an alcohol use disorder. When I share these numbers most people don’t believe me, even when I cite my sources (see Lopez-Quintero, Hasin, de los Cobos, Pines, Wang, Grant, & Blanco, 2011). 

The numbers tell us the undeniable truth that most people recover from substance use problems. The latest diagnostic manual (DSM-5) even states that an alcohol use disorder is “often erroneously perceived as an intractable condition,” and that the average person has a “much more promising prognosis” (p. 493). Based on a growing foundation of empirical support, the latest edition of the diagnostic manual for professionals recognizes that success, not failure, is the most common outcome for people who struggle with a substance use problem.

There is growing evidence that most people struggling with problematic substance use have a promising prognosis, and there is growing evidence that most people who succeed in recovery do so on their own. According to the National Epidemiological Survey of Alcohol Related Conditions (NESARC), 75% of people who achieve lifelong remission from problematic substance use do so naturally. Growing evidence that most people recover from problematic substance use without treatment suggests that many people find the treatment options available unappealing and/or unhelpful. Most treatment providers have the same core approach to treating substance use, which leads to the second point of this article: there is something close to a monopoly in the recovery industry, and therefore it is the recovery industry that fails people far more often than people fail in recovery.

The majority of treatment centers and providers root approaches to substance use treatment in the 12 steps of Alcoholics Anonymous and Narcotics Anonymous. Twelve-step, abstinence-only recovery certainly helps some people, but there are large numbers of people who find it unhelpful. The need is for a wider range of treatment options, and it is worth considering how professional help can be more effective in facilitating the efforts of people trying to change a problematic pattern of substance use. 

Research shows that what a trusted professional says about a medication has a tremendous impact on the medication’s efficacy. The impact of a professional’s statement about a medication is so profound that doctor-endorsed placebos have been shown to be more effective in treating headaches than actual headache medication accompanied with a doctor’s expressed reservations. In other words, a salt pill that a doctor says is really great alleviates a headache more effectively than an ibuprofen pill that a doctor says isn’t that good. 

Telling people at the onset of substance use treatment that they are likely to succeed would be beneficial, just like a doctor’s endorsement can help improve the effectiveness of a medication. I’ve seen the faces of countless people melt in relief when I tell them the odds are on their side, and that if they persist in their efforts they are almost guaranteed to succeed. Instilling hope fosters a mindset of success. What we expect has a huge impact on the outcome we experience. Thus, “professionals” telling people in recovery that they are likely to fail contributes to an expectancy of failure in a significant way. Fostering an expectancy of failure in recovery is an unconscionable practice, especially when the opposite is true.

Not only are people often lied to about the likelihood of their success in recovery; they are also often lied to about viable means to achieve success in recovery. According to NESARC, about 50% of people achieve remission from a substance use disorder through moderation. Treatment options for helping people moderate are under-promoted and underutilized. One of the foremost, internationally recognized professionals in the field of substance use, Andrew Tatarsky, PhD, describes the current climate in recovery as a “Tyranny of Abstinence.” The tyranny of abstinence in the recovery industry leads into the third aspect of recovery failure this article addresses: the common but misinformed criteria for success. 

The lie that most people in recovery fail is perpetuated by the misinformed criteria that perfect abstinence is the only success in recovery. AA and NA are of little use to people who are working towards moderating substances effectively. In AA and NA, any recurrence of substance use is branded a failure and the client is blamed (e.g. “He didn’t work the steps well enough”). The solution? Start over in the same treatment and try harder. Einstein eloquently reminded us that doing the same thing over and over and expecting different results is insanity. True to Einstein’s insight, trying different methods of treatment increases the likelihood of success. If treatment doesn’t work, the treatment is to blame, not the client. Substance use is the only area I’m aware of that blames treatment failure on the client.

Behavior change is an imperfect process. Being human is an imperfect process. How someone responds to a recurrence of substance use is far more important than the recurrence itself. In any other mental health or medical condition, a 99% reduction in symptoms would be viewed as an overwhelming success. Why then, in the treatment of problematic substance use, do so many continue to view a 99% reduction in substance use as a failure? Ninety-nine percent is an A+, end of story. The lie that perfect, 100% abstinence is the only success in substance use is an undeniable and unethical dilemma and helps perpetuate the lie that most people fail in recovery.

The actual criteria for substance use disorders say nothing about abstinence. Even the literal full definition of the word "sober" is “sparing” use of food and drink. The established criteria for problematic substance use emphasize clinically significant impairment or distress as a result of substance use. If a pattern of substance use is achieved that does not result in clinically significant impairment or distress, a person is considered to be in remission. Because the established, professional criteria for substance use disorders say nothing about abstinence, the notion that success in recovery equates to perfect abstinence is misinformed, unfounded, and arbitrary. Yet, abstinence-only treatment approaches maintain their stranglehold on the treatment industry. Dr. Tatarsky is accurate in describing the climate of recovery as a tyranny of abstinence. Due to the tyrannical, uniform climate of recovery options, treatment frequently fails the diversity of the population it attempts to serve.

Despite the monopoly-like dominance of abstinence-only treatment that often fails its customer base, there are a variety of specific, established ways to facilitate success that are available to those seeking help for substance use problems. Harm reduction offers a multitude of professionals willing to work with someone attempting moderation. Conveying trust in an individual’s judgment can help improve self-worth and empowerment, which are important steps to overcoming a problematic pattern of substance use. Cognitive-behavioral and motivational enhancement therapies have strong evidence to support their utility in helping facilitate progress in recovery. 

Providing secure resources, such as housing, family/social support, employment, and education, is another established method of helping people succeed. Unfortunately, the prevailing mentality in the recovery industry encourages the withdrawal of resources in order to “help” someone struggling with a substance use problem. People who crash a car or get dumped by a significant other due to actions when intoxicated probably won’t benefit from family members turning their backs on them too. Natural consequences are quite effective in encouraging behavior change on their own. If people are sliding they need a branch to grab onto, not water poured on them so they slide faster. The best way to help people who are hurting is to speak to their strengths and extend a helping hand, not shame them and kick them while they’re down.

Most families I work with have been told the lie that their only option to help a loved one struggling with substance use is to detach, withdraw support, and hope their loved one survives “rock bottom” and decides to change. Very few have been told the truth that as loved ones, they are in an optimal position to influence positive change in someone using substances problematically. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach aimed at encouraging loved ones using substances problematically to enter treatment. CRAFT boasts success rates of encouraging people to enter treatment that more than double the success rates of interventions. Not only do most individuals succeed in recovery, families can have a tremendous, positive influence on someone’s problematic pattern of substance use. Most people in recovery succeed, and most families can be an active part in that success.

To summarize, most people succeed in recovery; most do so on their own; perfect abstinence is not the only way to succeed; and there are a variety of evidence-based approaches to help people succeed in recovery. The preponderance of abstinence-only treatment options highlights a major gap between treatment desired and treatment available. The only failure I see in recovery is the failure of “treatment” itself to foster hope, convey compassion, and offer effective support to people who are hurting. It is a testament to the resiliency of the human spirit that most people recover in a culture that perpetuates the lie that most people fail.

Thaddeus Camlin, PsyD works as a substance use therapist for Practical Recovery in San Diego. His experience and training span a variety of settings from acute psychiatric facilities to individual outpatient services. He employs an existential-integrative methodology to offer personalized, self-empowering treatment. Email Dr. Camlin at thad.camlin@practicalrecovery.com

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