07/7/17

More Equal Therapies than Others, Part 2

© Allan Swart | 123rf.com

In his introduction to ”The Doctor’s Opinion” in the A.A. Big Book, Bill W. said A.A. favored initial hospitalization for the alcoholic who was “jittery or befogged.” It was imperative that the person’s brain was cleared so he then had a better chance “of understanding and accepting what we had to offer.” The reason to include Dr. Silkworth’s endorsement in Alcoholics Anonymous was to document a “medical estimate” of the A.A .12-Step plan of recovery.  “Convincing testimony must surely come from medical men who have had experience with the sufferings of our members and have witnessed our return to health.” But that was almost eighty years ago; and there have been some radical changes in the receptiveness of 12-Step recovery.

In modern addiction treatment there are a growing number of voices saying A.A.’s 12-Step approach should either be taken out of the treatment game or sidelined as a “recovery support service” (RSS) instead of being an integral part of the addiction treatment process. However, it would restrict or bench a valuable asset to addiction recovery. The rationales given for this generally follows two lines of argument.

One way is to portray A.A. and other 12-Step groups as religious or cultish in nature. This distortion stems from the secularization of American culture since the late 1930s when A.A. began, as well the failure to make a distinction between spiritual and religious consistent with 12-Step philosophy. See “Spiritual not Religious Experience” for a discussion of this distinction and a response to the accusation that the spiritual nature of A.A. disqualifies it from being used within addiction treatment. The second route is to suggest the 12-Step approach does not fit with the modern medical model of addiction treatment.

In the first ten years of A.A.’s existence the fellowship became convinced that organizationally it had to permanently remain nonprofessional. This was eventually formalized in Tradition Eight. Concurrent with that realization, was the origin of what would be called the Minnesota Model of addiction treatment. The Hazelden Foundation (now the Hazelden Betty Ford Foundation) blended professional and trained nonprofessional staff within a treatment approach based on the 12-Step philosophy of A.A. Throughout the 1950s, Hazelden honed it treatment model on three working principles.

First, alcoholism was seen as a primary condition and not just a symptom of an underlying disorder. Second, alcoholism was a disease and should be treated as such. The American Medical Association (AMA) officially identified alcoholism as a disease in 1956. Third, following the A.A. idea of the alcoholic suffering physically, mentally and spiritually, alcoholism was said to be a multiphasic illness. “Therefore treatment for alcoholism will be more effective when it takes all three aspects into account.” Abstinence was an integral goal of treatment.

These principles set the stage for a model that expanded greatly during the 1960s—one that has been emulated worldwide and has merged the talents of people in many disciplines: addiction counselors, physicians, psychologists, social workers, clergy, and other therapists. These people found themselves working on teams, often for the first time. And what united them was the notion of treating the whole person—body, mind and spirit.

Cracks began to appear in the dominance of the Minnesota Model of addiction treatment even as its hegemony grew in the 1960s. Methadone maintenance as a treatment for heroin addiction arose in the early 1960s. In the 1980s, the biological model of psychiatry began its ascendency and in 1991 the AMA took the further step of endorsing a dual classification of alcoholism as both a psychiatric and a medical disease. In 1992 SMART Recovery began. “SMART Recovery is based on scientific knowledge, and is intended to evolve as scientific knowledge evolve.” In 1994 Moderation Management became a self-help group for individuals who wanted to moderate, not abstain from alcohol.

Addiction professionals developed diverse alternatives to addiction treatment centered on 12-step philosophy. Stanton Peele developed Life Process Program as an alternative to 12-Step treatment, which he now offers as an online program. Marc Lewis wrote The Biology of Desire, refuting the medical view of addiction as a brain disease. He conceived it as an extreme form of learning.

Lance Dodes wrote The Sober Truth, purportedly debunking the bad science behind 12-Step programs and the Rehab industry. It claimed to be an expose of Alcoholics Anonymous, Twelve Step programs and the rehab industry—how “a failed addiction-treatment model” came to dominate America.

David Sinclair developed the Sinclair Method, which conceived of alcoholism as a learned behavior, one that can be removed by the behavior modification principle of extinction. “The solution discovered by Sinclair effectively means you have to drink yourself sober!” And there are others. But the medical model, although it has been modified, remains supreme in addiction treatment.

In the 1990s, a movement began in medicine to develop evidence-based practices (EBP). A widely accepted definition of EBP by Dr. David Sackett is that EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”  When applied to addiction treatment, the principle is generally referred to as evidence-based treatment (EBT). The National Institute on Drug Abuse (NIDA) simply referred to EBTs as treatment approaches “that have an evidence base supporting their use.” The website GoodTherapy.org elaborated, saying that EBT was “treatment that is backed by scientific evidence.” This referred to extensive research, which has been documented and demonstrated to be effective on a particular treatment.

Consistent with this understanding, NIDA listed a manualized Twelve Step based treatment model called Twelve Step Facilitation (TSF) as an evidence-based behavioral therapy. TSF actively seeks to engage substance abusers in becoming involved in 12-Step groups, “thereby promoting abstinence.” However, a writer and researcher for Handshake Media, Laurel Sindewald, concluded in her article, “AA Is not Evidence-Based Treatment,” that NIDA wrongly listed TSF as evidence-based.

In Part 1 of this article, “More Equal Therapies than Others,” is a description of TSF and a discussion of how Sindewald’s critique wrongly and inconsistently grouped A.A. and other 12-Step groups with treatment approaches like the Minnesota Model and TSF that use 12-Step philosophy. Her provocative title is the result of mistakenly grouping A.A. and treatment approaches based on 12-Step philosophy together; and then illegitimately transferring her critique of these 12-step treatment approaches to A.A. A.A. sees itself as a fellowship and not a treatment. Here we will briefly look at how Sindewald’s narrowing of the NIDA sense of “evidence-based treatment” allowed her to conclude TSF was not evidence-based.

As was described in Part 1, Sindewald gave a biased description of 12-Step philosophy, stating it viewed addiction as merely “a spiritual disease born of defects of character.” Twelve Step groups supposedly said they were the only cure, “involving faith in a higher power, prayer, confession, and admission of powerlessness.” Contrasted with the NIDA definition of addiction as a disease of the brain, she asked how TSF as a professional medical treatment could be based on an understanding of addiction as a spiritual disease. Note the rhetorical sleight-of-hand in how she conveniently left out the A.A. and 12-Step understanding of addiction as a physical, mental and spiritual illness/disease.

Another place Sindewald used the same tactic was where she defined evidence-based. “In this article, I define ‘evidence-based’ to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. Note how her sense of “evidence-based” is more restrictive than NIDA, GoodTherapy.org and even Sackett’s widely acknowledged sense of evidence-based practice for medicine.  Her criteria seem to be even more restrictive than the American Psychological Association’s criteria for well-established “empirically validated treatment” in the “APA Task Force on Promotion and Dissemination of Psychological Procedures” Refer to Table 1 for the criteria.

Gianluca Castelnuovo wrote an article for Frontiers in Psychology on “Empirically Supported Treatments in Psychotherapy.” Consistent with the broader NIDA sense of evidence-based, he said the term evidence does not have one single definition. “evidence-based practice (EBP) includes many forms of evidence other than data from RTCs [randomized control trials].” There are two contradictory visions of what causes change in psychotherapy. One approach emphasizes the primacy of therapist and technique. The second vision focuses of the patient-therapist relationship and what the client brings to the therapeutic relationship.

The first vision sees the specific methods used by the psychotherapist as accounting for, by far, most of the changes in therapy. “Other factors (e.g., therapist relational qualities, patient–therapist relationship) are secondary, at best. This viewpoint is seen most notably in what have been termed the EST and EBP movements.” This approach conducts tightly controlled outcome studies, where specific treatments are pitted against one another or a control group and applied to specific disorders, usually as defined in the DSM. This describes the Project MATCH study, for which TSF was developed. This first sense proceeds from a medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.”

The second view of psychotherapeutic change attributes most positive therapeutic outcomes to client factors (40%) and the therapeutic relationship between client and therapist (30%). The technique used and the skill of the therapist accounts for the remaining 30% of positive therapeutic outcomes. This so-called “common factors approach” then discourages attempts to pit one therapy against another or against a placebo group of no treatment (clients placed on a waiting list) as ultimately doomed to failure, since all therapies have the same potential for positive outcomes (the dodo bird effect).

When discussing the significance of common factors in “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Barry Duncan noted how experienced therapists know psychotherapy requires the unique tailoring of a therapeutic approach to a particular client and circumstance. And if a therapist attempts to do therapy by the book, it often doesn’t go very well. There are limitations to manualized therapies, even TSF.

The structure minimizes the factors brought to therapy by the client. It restricts or eliminates the therapeutic relationship between client and therapist. And it emphasizes the factors (therapist and technique), which typically have the least positive outcome effects. If you want to determine whether a therapeutic approach is “evidence-based” or “more equal” than other therapies when treating a designated DSM disorder, you will likely use a structured, manual-based treatment.

For more information of the therapeutic power of common factors and the dodo bird effect, see the above-linked article by Barry Duncan. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”; or “The Dodo Bird Effect” and “Another Brick in the Wall” on this website. If you are interested in exploring “the science behind 12 Step recovery,” try If You Work It, It Works! by Joseph Nowinski.

06/27/17

More Equal Therapies than Others, Part 1

© Allan Swart | 123rf.com

In the classic novella, Animal Farm, by George Orwell, the animals of Manor Farm revolted and drove the drunken and irresponsible farmer Mr. Jones from the farm. They renamed it “Animal Farm” and adopted the Seven Commandments of Animalism, the most important of which was the seventh: “All animals are equal.” Eventually the pigs cemented their role as the leaders of Animal Farm, and this commandment was modified to say: “All animals are equal, but some animals are more equal than others.”  Barry Duncan adroitly applied this example of double-speak in his discussion of those who apply the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration” to declare that some psychotherapies were more equal than others.

Two other articles, “The Dodo Bird Effect” and “Another Brick in the Wall” explored Duncan’s argument for the power of common factors in psychotherapy and the dodo bird effect, an alternate way of understanding the process of therapeutic change from the dominant medical model of therapeutic change described above. He developed this position in: “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” and a book he coauthored: The Heart & Soul of Change.” Here I want to explore how the Orwellian sense that some therapies are more or less equal than others runs wild in addiction treatment.

The National Institute on Drug Abuse (NIDA) defined addiction as “a chronic, relapsing brain disease” because drugs changed the brain—its structure and how it worked. Here is a short YouTube video of the Director of NIDA, Nora Volkow, discussing this view of addiction. This definition was purely a physiological, biomedical understanding of addiction. Philosophically, it also seems Volkow assumed there is no mind; that human traits like “free will” were products of the biology of the brain. Note where she said “free will” was a product of the biology of the brain.

As in medical practice, addiction treatments are quantified according to an evidence-base of effectiveness. Here, the buzzword is “evidence-based treatment.” NIDA has a listing of  “Evidence-Based Approaches to Drug Addiction Treatment,” which it categorized as “Pharmacotherapies” and “Behavioral Therapies.” The NIDA introduction said the section “presents examples of treatment approaches and components that have an evidence base supporting their use.” One of the behavioral therapies NIDA listed as “effective in addressing substance abuse,” was “12-Step Facilitation Therapy” (TSF).

This 12-Step-based treatment approach was developed by Joseph Nowinski, a clinical psychologist as part of the Project MATCH study into the effectiveness of three different perspectives on how to treat alcohol use disorders (then described as alcohol abuse and alcohol dependence in the DSM, the psychiatric Diagnostic and Statistical Manual). In his book, If You Work It, It Works!, Nowinski said many academic researchers were highly skeptical that TSF would work at all, as A.A. and the Twelve Step approach was poorly understood. “Many academic researchers inclined to think of it more as a cult or quasi-religion than a serious programmatic approach to recovery from addiction.”

The two other interventions, Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) had been extensively studied. But Twelve-Step interventions had not been the subject of significant, rigorous research. So Nowinski developed TSF, a psychosocial treatment manual based on engaging the individual in 12 Step support groups such as Alcoholics Anonymous (A.A.).

In 1997 published results from the MATCH Research Group showed that all three interventions (CBT, MET and TSF) were effective in reducing drinking and increasing abstinence after treatment. One year after completing treatment those who were in the outpatient section of MATCH were sober over 80% of the time. And TSF was found to be equally effective for individuals who had been diagnosed as an alcohol abuser rather than as alcohol dependent.

These findings were so unexpected that some long-standing critics of AA and its Twelve Step program went so far as to question whether the MATCH data were somehow falsified. Of course, nothing could be further from the truth. The reality, rather, was what some skeptics could not abide: the idea that the Twelve Step approach works.

Nowinski said his goal in writing If You Work It, It Works was to make information on the effectiveness of Twelve Step recovery, now documented in academic journals, available to the general public. His goal was “to stand for the Twelve Step model in the face of long-standing and unchallenged criticism and skepticism, much of which is not based in fact.” Equally important, he hoped that people on the fence about going to an A.A. meeting “will benefit from learning about the science (as opposed to the myths) of Twelve Step recovery.”

Nowinski referred to a long-standing bias against the Twelve Step approach to recovery. He said it was regularly portrayed as a quasi-religious approach, and then rejected because it is not a structured treatment approach. Therefore it lacked a clear demonstration of its scientific, evidence-based effectiveness. If an addiction treatment approach, like TSF, used the 12 Steps or actively encouraged clients to participate in 12 Step groups like Alcoholics Anonymous (A.A.) or Narcotics Anonymous (N.A.), it was often judged to be “a less equal treatment” than others. An article by Laurel Sindewald for The Fix, “AA Is not Evidence-Based Treatment,” illustrates this bias.

The author said she had previously done a literature review that found insufficient evidence to support the use of 12-step groups as treatment, so she was surprised the Surgeon General included TSF as an evidence-based behavioral treatment for addiction in Facing Addiction in America. She admitted to a personal bias, which apparently was against the spirituality of 12-step groups and what she referred to as “12-step philosophy.” It seems that since TSF encouraged participation in 12-Step self-help groups, it was suspect as a “less equal” treatment approach, because it retained “ the spiritual emphasis of 12-step philosophy.” However, she would “set aside her bias” in her assessment of TSF, in order to give it a scientific, objective assessment. But that does not seem to have been the case.

Sindewald noted where the Surgeon General’s Report classified TSF as a “professional behavioral treatment,” but then immediately asked: “How could a professional medical treatment be based on a definition of addiction as a spiritual disease?” She stated (without any supportive citation) that Twelve-Step philosophy stipulated that addiction was a spiritual disease born of defects of character; and that 12-step groups were the only cure. She later compared Twelve-Step literature to religious literature like the Bible and the Qur’an and contrasted Twelve-Step philosophy with medical science. She gave an extended quote from the A.A. “Big Book” of Alcoholics Anonymous, which she said represented Twelve-Step philosophy saying it can never be wrong. Her bias against spiritual/religious philosophy was all through her critique.

The AA pamphlet “How AA Members Cooperate with Professionals,” stated that A.A. is not in competition with anyone. “Our ability to help other alcoholics is not based on scientific or professional expertise.” Unpacking principles articulated in AA’s Twelve Traditions, the pamphlet also said: “A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes.” In his essay on Tradition Six in Twelve Steps and Twelve Traditions, Bill W. gave a brief history of early A.A.including attempts to institute A.A. hospitals and get involved in education. He noted where these activities raised confusion. “Did A.A. fix drunks or was it an educational project? Was A.A. spiritual or was it medical? Was it a reform movement?”

These adventures implanted a deep-rooted conviction that in no circumstances could we endorse any related enterprise, no matter how good. We of Alcoholics Anonymous could not be all things to all men, nor should we try.

In the same chapter of the A.A. Big Book, which Sindewald cited and linked, “How It Works,” there is a discussion of resentment being the “number one” offender, destroying more alcoholics than anything else. “From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically.” So there is an understanding of alcoholism as a spiritual, mental and physical illness/disease.

Also in that chapter you will find the 12 Steps described as a suggested program of recovery. “The principles we have set down are guides to progress. We claim spiritual progress rather than spiritual progression.” So it seems that AA does not present itself as the only cure; nor does it describe alcoholism merely as “a spiritual disease born of defects of character.”

A clear distinction by the author between TSF, A.A., and rehab programs using the 12-Steps isn’t maintained in her critique. In her article for The Fix, she said she used “12-step approaches” to refer to all 12-step self help groups, all 12-step-based rehab programs and TSF. However, in another article she wrote previously for Handshake Media (linked as her literature review), she said: “TSF is distinct from AA and other 12-step support groups.” Yet in her conclusion for “AA Is not Evidence-Based Treatment” Sindewald said “after exhaustive research” she could assert with confidence that 12-step approaches—including TSF—were not evidence-based treatments. She called for the reallocation of funds away from these approaches to those “that can be studied rigorously and without such crippling methodological limitations.”

With regard to A.A .and other 12 Step groups, she was right when she said they were not treatment approaches to addiction recovery. A.A. is not developed as a treatment approach and doesn’t claim to be a treatment approach. The A.A. website said: “Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem.” It is also self consciously nonprofessional, stating in Tradition Eight, “Alcoholics Anonymous should remain nonprofessional.” As fellowship organizations, A.A. and other 12-Step self-help groups are not structured in ways that can be easily studied by researchers who want to assess their effectiveness within a structured medical model of therapeutic change.

But Twelve Step Facilitation is considered to be a treatment approach. According to the NIDA description of “12-Step Facilitation Therapy,” TSF is a manual-based, structured treatment approach. It is “designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence.” And TSF is listed by NIDA as an evidence-based treatment approach, the same organization, by the way, that Sindewald referenced as defining addiction as a brain disease. Apparently NIDA doesn’t agree with her that TSF is not an evidence-based treatment approach.

It seems Sindewald’s failure to acknowledge the difference of A.A. and other 12-Step groups from the various addiction treatment approaches that apply “Twelve-Step philosophy” was intentional. It sets up a straw man argument that illegitimately transfers a critique of the TSF treatment approach onto 12-Step groups. It also seems that Sindewald’s claim to have set aside her bias while she examined Twelve Step treatment philosophy and TSF was not true.