Choices in self-help for substance use disorders

(Author’s note: This post follows from the earlier post on new findings about addiction. I had originally added this as a comment to further discuss alternatives to AA and other 12-step approaches. I have moved that comment into this separate post.)

S.M.A.R.T. Recovery (Self-Management and Recovery Training) was started by a group of mental health professionals who were formerly part of Rational Recovery (RR), a non-12-step abstinence based support and self-help organization based upon Albert Ellis’s Rational-Emotive Behavior Therapy (REBT).

RR and SOS (Secular Organizations for Sobriety / Save Our Selves) were the first mutual help organizations to offer alternatives to the dominant AA/12-step approach, at a time when choice was needed. Both groups raised concerns about the legal and ethical issues involved in mandating people into a program that many felt to be religious in nature.

Rational Recovery Splits from SMART Recovery

In the mid-1990′s, the founder of Rational Recovery, Jack Trimpey, severed his relationship with REBT and also disaffiliated from the group of professionals who had assisted the Rational Recovery organization as Professional Advisors. Trimpey also disowned his original REBT-based book, “The Small Book,” and published “Rational Recovery: The New Cure for Substance Addiction.” After a court case involving the name “Rational Recovery ” the former professional Advisors started a new organization called SMART Recovery.

Mr. Trimpey’s claims included the assertion that therapy of any type was of no use in recovering from addiction, the belief that cognitive-behavioral therapy ignores the only real cause of addiction and is usually counterproductive, and the often-repeated complaint that counselors and therapists are part of a huge conspiracy that seeks to keep addicted people dependent on recovery movements and their own services. His teaching tool, “Addictive Voice Recognition Training”, was presented as all one needs to completely recover from addiction permanently, and his position was that offering any other measures or services to addicted people is unethical. Mr. Trimpey also eliminated the Rational Recovery support groups in favor of Internet-based subscription training, seminars, and teleconferences, all of which he runs as a business.

While I was initially quite encouraged when I heard Mr. Trimpey speak in 1991, and I found Rational Recovery to have many useful concepts and tools, and to be a refreshingly direct way of looking at addiction and relapse prevention, Mr. Trimpey’s recent changes to his model and his antagonism toward any and all professionals providing substance abuse services has led me to no longer recommend RR as a resource. Some of the basic concepts -especially the addictive voice and addictive self-talk – are useful to many people, and indeed could be all that is needed for some people – even some seriously addicted people – to successfully quit for good on their own.

Unfortunately, Mr. Trimpey’s transformation of what was originally a “choice” in addiction care into his own only true way to cure addiction has made it problematic as a tool for many addicted people. His positions on matters related to public policy have also taken a turn from merely condemning the treatment community to staking out a somewhat extreme conservative view which seems to equate liberal politics with drug addiction. In my opinion, all of this rhetoric can present challenges for a person who just needs tools for staying clean and sober. The political speech, while it may be bracing for those in my field, can be distracting and even discouraging for someone in the early stages of recovering from addiction. For all those reasons, I would urge anyone with substance abuse issues to approach Rational Recovery in its current form with caution, since there are a number of other resources currently available that retain the mutual support aspects of substance abuse self-help.

The core concept of RR – that addiction hijacks some aspects of our thinking and requires us to adopt a critical ability when we monitor our own thoughts – remains useful. A summary of this using different terminology, and without most of the policy arguments, can be found at “The Orange Papers.”  This explanation is part of a website that is largely critical of AA, but can be used as a tool in itself.

A Non-Abstinence Approach: Moderation Management

There is an organization called “Moderation Management” that follows a newer trend called the Harm Reduction model. This is based on the premise that if drinking a lot is causing someone problems, perhaps learning to drink less would cause fewer problems.

Unfortunately, this idea is not well suited to anyone whose drinking has progressed beyond the stage of heavy drinking. In my view, it works better as a public health strategy than as a plan for managing one’s own alcohol (or drug) use. The main problem with Moderation Management is that many (if not most) chemically dependent people harbor unrealistic hopes that they can return to drinking “normally” afer alcohol has caused them problems in living. The premise of MM thus fits a little too easily into the whispering that the addicted brain engages in 24/7, telling the substance-dependent person that it might be possible to cut down rather than quitting.

Some writers, notably Herbert Fingarette, Jeffrey Schaler, and Stanton Peele, have taken a position that addiction in all its stages is basically a choice to self-indulge. This opens the possibility that changing those choices can take the form of moderating one’s intake. As a counselor, I have had to admit that a significant number of people I have worked with (or, often, their relatives) have at some point been diagnosed as alcohol dependent, and later settled into a pattern of drinking less frequently and “getting by” with far fewer problems than when they were drinking in an “alcoholic” way. Those individuals appear to have – at least for themselves – refuted the assumption that there is a “loss of control” involved in addiction.

While this goal of moving from problem drinking to “lower risk” drinking has undoubtedly led to a less destructive behavior pattern for some people, for many others it is just too much effort to be worth it. For those people, quitting drinking is less difficult and less stressful than trying to control their drinking. 

Unfortunately, for still other individuals, a moderation-based program can be a recipe for disaster. One of those, sadly, seems to have been the founder of Moderation Management herself, Audrey Kishline. She concluded a number of years ago that she could no longer manage her own drinking and started attending AA meetings. Not long after, she was involved in a terrible accident while driving drunk – leading to the deaths of two people. Despite the fact that she never claimed to be a moderate drinker (and in fact was attending AA) when the accident happened, her tragedy underscores the risks involved in trying to drink moderately for anyone who has had problems with alcohol or drugs.

But I admire the idea that choice should be offered to people who may want to change their behavior when it comes to alcohol. In fact, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has a website called “Rethinking Drinking” that takes a more harm reduction approach and makes a significant move away from the old “Are you an alcoholic?!” approach.

 
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