Where Should the Power in Addiction Recovery Come From?

By Dr. Richard Juman 10/01/15

Tom Horvath, President of SMART Recovery, discusses a new association for providers of “self-empowering” treatment.

Where Should the Power in Addiction Recovery Come From?
Tom Horvath Tom Horvath

Is there a necessary and sufficient “power” source for addiction recovery? Twelve-step programs encourage members to accept a “higher power” as the key element in recovery. Medical providers and advocates of the “hijacked brain” concept of addiction might argue that pharmaceutical power is the logical fuel of recovery, as manifested in Medication-Assisted Treatment. Others, including Dr. Tom Horvath, believe that the power that generates solid recovery should come from within the client, and views treatment as a vehicle for promoting “self-empowering” recovery. In many such cases, clients will opt for a program of recovery that does not necessarily include abstinence from mood-altering substances as an immediate or even an eventual goal. Here, Dr. Horvath describes the concept and SEATA, the new association and directory of like-minded treatment providers…Dr. Richard Juman

Richard Juman: Please tell our readers about SEATA and especially what is meant by the concept of "self-empowering" in the context of addiction treatment?

Tom Horvath: The term "self-empowering" contrasts this approach with the powerlessness approach of Alcoholics Anonymous (AA) and other 12-step groups. Clients embarking on any type of recovery process enter it having made decisions with a large short-term focus, to the detriment of their values and their long-term interests. To say it one way, they'd rather spend money to get intoxicated immediately than spend money on goals that could not be accomplished as quickly. In the 12-step approach, it is assumed that individual willpower alone is insufficient to sustain recovery (although not necessarily other goals), and that therefore reliance on a higher power, a group, and a sponsor (a mentor in the 12-step approach) is necessary. In self-empowering recovery, it is assumed that, even though willpower is weak at the beginning, it could be nurtured to the point that one no longer needs to be "in recovery." Both approaches start with their adherents in the same place, but lead them to opposite places. Both approaches can work. However, often one approach appeals to someone much more than the other. 

Many individuals seeking recovery do not realize that the self-empowering approach exists. The purpose of the Self-Empowering Addiction Treatment Association is to assist providers to make that approach more visible to the public.

So, is a rejection of all four of the following elements integral to SEATA membership? The elements being:

1. 12-step ideologies

2. the concept that people with addictions are inherently powerless against their drug of choice

3. the need for some type of higher power beyond the client's own resources being necessary in order to succeed in recovery, and

4. the notion that "recovery" essentially equals abstinence and must be lifelong 

Would all of your members agree that all four of those aspects are contrary to their perspectives and approaches? 

I don't know of any treatment facilities that genuinely conduct both 12-step based treatment and self-empowering treatment, but offering both types of treatment is possible. That arrangement probably requires separate staff in separate facilities. Self-empowering treatment is not 12-step based, not powerlessness based, not oriented around the involvement of a higher power (but is fully comfortable with the existence of one), and not oriented around abstinence necessarily, in any timeframe.

What would you guess to be the percentage of treatment facilities that provide self-empowering treatment? And why, despite the fact that the 12-steps were not really intended to be the foundation of professional treatment, do you think so many facilities still base their treatment around 12 steps?

The last careful assessment I'm aware of found over 90% using a 12-step approach. I suspect this percentage is still roughly accurate. Therefore, self-empowering treatment is around 10% of the field or less. 

As to why most treatment centers use the 12-step approach, I see several influences: the belief that the 12-step approach is "the only way to recover," the 12th step specifically, and money. The 12th step:

"Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs."

Many people in 12-step recovery would be motivated to work in the industry as a method of carrying out this step. Many might also be willing to do so at reduced wages, rationalizing that lower wages are acceptable or even desirable given that the 12th step is being accomplished. Because 1) the 12-step approach doesn't require a high-level professional to implement, 2) drug counselors (the primary providers in the field) are often in recovery and willing to work for lower wages (and all businesses work to lower expenses), and 3) "12-step is the only way to recover," we have the current system. An additional money factor is that because most treatment (roughly 3/4) in the US is paid for by the government, clients are not direct consumers. It is harder to complain about treatment you are getting for reduced cost or free. The government keeps driving costs down (via budget cuts) but complaints are minimal. In short, there are few incentives to change the current system. 

I hope this question gets scientific study, because there must be other factors as well. What is truly remarkable is that we have an addiction treatment system running so counter to scientific evidence. Powerful forces must be at work to maintain this system. It would be good to understand them better, in order to change the system. My primary suggestion for doing so is making a master's degree the minimal requirement for working in addiction treatment. That requirement already generally exists in mental health treatment, which seems to function at a much higher level than addiction treatment. 

Your comment about the potential benefit of increasing the amount of education and training required to provide substance use treatment begs another question: Should anybody working in the substance misuse arena also have more general training about treating mental health issues, as so many of our clients present with both substance and psychiatric problems? Also, do you think that SEATA members already tend to have those qualifications? 

I could have clarified that the master's degree would be in mental health, with additional or included coursework in addiction. I think that including a small proportion of drug and alcohol counselors under the close supervision of licensed mental health professionals is a meaningful addition to services (and we do this at our facilities at Practical Recovery). Yes, I expect that, more than average, SEATA providers are licensed mental health providers.  

So far you've most clearly defined what self-empowering treatment isn’t: It is “not 12-step based, not powerlessness based, not oriented around the involvement of a higher power (but is fully comfortable with the existence of one), and not oriented around abstinence necessarily, in any timeframe.” But what would you say are the defining positive and essential qualities of self-empowering treatment? 

A self-empowering approach helps the individual build competence and connection to others. Competence would primarily focus on recovery specifically (such as learning how to maintain motivation and how to cope with cravings) but probably would also include related issues (such as learning greater social skills, how to cope with negative thoughts, or relaxation techniques). Competence and connection form the two foundations of recovery and a good life. As Freud suggested, a person needs to know how to love and to work. There might be a wide range of ways that a self-empowering provider helped someone with these broad goals, while honoring the individual's choices about recovery and about life. 

What criteria are you using to determine that a facility or provider should be included in the directory?

For the moment, we are simply asking potential providers to review the provider guidelines and join SEATA if they meet them. Their clients will have the chance to comment on how closely a provider adheres to SEATA's guidelines.

What do you envision with respect to how SEATA might evolve?

SEATA might evolve in several ways, all of which would arise from becoming a more formal organization. For instance, we need conferences that are provider oriented (rather than research oriented) but have a self-empowering focus. SEATA might further elaborate ethical standards and provide support for providers to understand, reach and maintain these standards, possibly to include certification or accreditation. Or SEATA might become a publisher. Alternatively, the self-empowering perspective might become sufficiently available in other organizations that SEATA no longer needs to exist. However, I suspect SEATA will be needed for a long time. 

Tom Horvath, Ph.D., ABPP, is founder and president of Practical Recovery, a self-empowering addiction treatment system in San Diego, past president of the American Psychological Association’s Society of Addiction Psychology (Div 50), the world’s largest organization of addiction psychologists, past president of the San Diego Psychological Association, author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions (listed by the Association for Behavioral and Cognitive Therapies as a “Self-Help Book of Merit”), and the volunteer president of SMART Recovery, an international non-profit offering free, self-empowering, science-based mutual help groups for abstaining from any substance or activity, for most its existence.

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.