Abstinence Is Not Treatment
So why is it the primary treatment in many Addiction Treatment Centers?
This article is going to be critical of the siloed care of a large part of addiction treatment centers, detoxification centers. By default, it will be critical of 12-step programs, because that is part of the problem with our lack of success in treating addiction with abstinence. There is a perception, in our society, and perpetuated by two peer fellowships with a unique perspective, that all people with Substance Use Disorder want the same thing, abstinence.
Abstinence is the safest option, and the most effective form of harm reduction there is for any Substance Use Disorder. This is a fact. What is also a fact is that “complete abstinence” is not a treatment for anything. It is a religious concept and the most radical form of harm reduction, nothing more. It is using the application of western spiritual principles to apply the solution that society and religion wants. It is not treatment, it is the stigmatizing of a population that has entered into a taboo that it feels the person created, and can be solved by God. Abstinence did not stop people from having sex, and it won’t stop people from getting high on substances.
The concept of abstinence as the path to recovery from severe addiction originates from a temperance movement that would eventually help create the culture of 12-step programs after the end of prohibition, the great first failure of forced abstinence. After that failure abstinence needed to be created through culture, not the law with regards to at the time, alcoholism. As we know, the second great failure of forced abstinence, our drug war, is still going on.
How does all this connect to the detoxification center model and their lack of success over the last 70 or more years? The members of AA and NA have dominated the employment pool of this model which matches what they believe, and not reality. They did this with no evidence based reason other than the confirmation bias within their own organizations.
12 Steppers do not choose, for the most part, to work in other areas such as medication clinics, or healthcare, for this reason. If they did, they would be uncomfortable with policy that goes against their beliefs. There are also very good professional 12-Steppers, but they do not drive the norm of addiction treatment culture. They are able to compartmentalize their beliefs, but because they are involved in the same philosophy, they will often not challenge or push back on this entrenched dysfunctional culture. Kind of like a good cop. They do what they can, but they are not going to point out tactics of others in their peer group.
Professionals endorse this cultural bias that allows them to function in this way. Their repeat business model aligns with the goals of AA and NA. Capitalism will capitalize any place it can, and every business model likes repeat business. This is the perfect storm of greed and ignorance that our country loves to reinforce. Many of the professionals, such as the doctors and nurses, are also in recovery, and those that aren’t are surrounded by people using abstinence based recovery. Immersion in a subculture will at the least change the persons views, if not fall in line with them.
This happened because of a need for direction at the time, and a lack of people to work in this field. Through stigma an organic cultural Frankenstein of disempowerment and religious thinking somehow became a clinical modality. It remains today as a profit measure to increase bank accounts at the expense of the tax payers and insurance companies, and most of the insurance companies providing this care are subsidized through Medicaid so really it is just the taxpayer footing the bill for this faulty system of mixed messages and noise about how everyone is going to help you, because you can’t help yourself.
We create the stigma, ignore people into pockets of severe addiction, then cycle them in and out of a need for perfection with the end for most being suffering and death. If they try and take medications and have progress the support from peers just is not there, or is a form of harm reduction that is not honest. Unconditional love can include facts, such as you are statistically not likely to successfully use cocaine, fentanyl, opioids, methamphetamine, and only slightly statistically better for Alcohol, but that drug also has some of the worst physiological long term side effects to health.
This culture is the end product of clinicians and doctors who have allowed this to occur over the last 70 years, not these fellowships. Their goal is always clear. To carry their message. This story may criticize the tactics, but none of this is the fault of these fellowships, they are exactly what they say they are. Their ways are valid, and should be presented as an option because of their success. It is unethical for clinicians and administrators to allow commitments, their versions of a mission, to ever be a part of a required group. This is what is the fault of the treatment providers, but they have to keep the machine going. If they started integrating with medication clinics to create integrated care many AA and NA people would not work for them.
There is also fault to be laid at the feet of the medical and behavioral areas of health care. They pawn everything off to the addiction treatment centers, knowing their primary modality is still abstinence and religion, but these organizations also draft off of the success of the peer model in mental illness for recovery. This affirms that other professionals think of these models as peer groups for people with SUD. They are actually completely opposite views on recovery. They function on the 10 Fundamental Components of Recovery which is about empowerment and person centered recovery and treatment.
Our behavioral health professionals may be most at fault. They created a silo within the silo that should be treating addiction. Rather than challenge powerful peer groups, they co-signed them. Creating a confusing landscape of mixed messages trying to catch up.
Things are getting better for people with Substance Use Disorders, but this silo of detoxification centers still run in much the same way. The detox formula is they give you meds and drill you with 12-Step jargon and boredom for 5-7 days along with a healthy dose of non-person centered treatment or care. Their employees impose their values, rather than evidence based practices, and wait for you to come back. If you do stay sober they’ll hire you too, and take all the credit for your hard work.
This public image persona of both detoxification centers and their allies in AA and NA, which is that of knowing what is best for alcoholics or addicts, leaves out one fact. Alcoholics or Narcotics Anonymous do not speak for people with Substance Use Disorder. Most people with Substance Use Disorder are not their members. Their modality is that you must admit that you have a disease (alcoholism, or addiction) of the spirit, but the etiology is vague because it is whatever you make up, you just have to have it and identify with it. We know that if you are immersed in repetitive messaging for long enough it may take hold, that is their thing.
This disease is then defined as always progressive in nature, and leaving you with a mental obsession, physical compulsion, and spiritual loss of values. That is in fact a fair antiquated definition of addiction. What is not true is that addiction is not always progressive, it can be chronic and stable, and it can be changed by the person at any time. Addiction, just like SUD, represents a range of manifestations and forms of recovery unique to every person with SUD.
Their philosophy meets what culture wants, which is a clean black and white answer, that will always be prioritized over evidence and reality. Stigma is the license for others to ignore the problem. We teach families to isolate and use “tough love.” Boundaries are important, but the opposite of addiction is connection. That is something this writer and these fellowships agree on, we just have two different views on where boundaries lie. They choose boundaries that leave them with the power by using coerced connection and imposing values.
This formula has dominated over a system of failed abstinence and pervasive disempowerment towards people already disempowered by addiction for many decades, and it will take time to change. Many have lost loved ones that could have been saved by medications, other behavioral modalities, and most importantly, simple person centered care. 12-Step groups are very skilled at presenting their fellowships as person-centered care when they are the opposite. It is person centered, if you believe everything they tell you to do and do it. The focus is on the person taking your power away rather than building on your own empowerment. They still have a firm belief that addiction is tied to ego, because of the religious ideology. In fact if there is a common underlying trait in people that suffer from severe addiction, it is more commonly PTSD.
Their minimal success is all that is ever elevated in our society. When was the last good movie of the guy on the clinic smoking weed who is loved by his family? When is that guy getting a news segment on the evening local good news minute. oloTrust me that recovery exists. As a nurse working in addiction I have seen a lot of recovery within medication clinics, people developing healthy boundaries, and successful use of many different alternatives that are less harmful. This form of recovery is never acknowledged in a good light, because that is not what society wants.
One reason for this lack of insight into reality is that 12-step members, like religions, do not explore other options or any other information. They have their answer and that is now everyone else’s answer, and if you don’t think that way you are not being honest with yourself. Like all rigid belief systems, they stick to the message of abstinence is best, and any criticism is labeled as judging their recovery. They do not want to coexist with other ways to recover, yet any new way needs to be inclusive and defer to their way.
That is on a personal level, on an organizational level. They learned all the tactics they have from the best at converting people, the Catholic church. On an organizational level, they churn out their philosophy and consider all treatment an “outside issue.” They say they function on attraction, rather than promotion. Yet, most people will find out about them in either through treatment or the justice system. They go into treatment centers and you have to listen to their message to comply with treatment, or the justice system requires you go for probation. The latter is on the decrease, which is appalling that the justice system is ahead of treatment on actual treatment.
If other forms of recovery were acknowledged by 12-step groups it would break their matrix. That is why they have no opinion on anything, the do not benefit from coexistence because they don’t want members to know there are other ways to recover. The framework is that your recovery begins at the commencement of your sobriety or clean time. Talking about substance use in any way other than all substance use leads back to your “drug of choice” is a third rail topic in these fellowships, with the exception of nicotine and caffeine.
This is ironic, considering their own disease process and belief that all roads lead back to your primary addiction, may actually be a factor in the philosophy failing, if we were to apply it equally to all substances. This type of double standard handcuffs any honest discussion about why one may want to continue to use less harmful substances, let alone the opinions on actual medications. Is nicotine and caffeine just MAT for people that are sober and clean? Tell them you smoke weed, that is always an interesting topic.
These fellowships don’t have opinions on anything their members do, shirking responsibility for controversial methods imposed by the people their fellowships create. The basic template of any cult, when you say it like that. By the way, cults are not a bad thing. They come out of society creating a need for shelter related to not feeling a part of. In the case of people with SUD that suffer addiction, outright social stigma created these ones. Cults can be very effective for some and being in one does not make a person bad, in fact it can be an attribute and comfort to many to have solid beliefs. It could be argued that all religions are cults or have the capacity to become one.
This is the fact that all belief systems fail to mention about themselves: any solution for a subset of people is not a universal solution for anything in humanity. All cults should be allowed until they are deemed to be abusive or harmful, which is the paradox of freedom of religion and freedom from religion. All belief systems, including religions, are coping mechanisms for a subset of human beings, not universal solutions for all. Imposing rigid subcultural norms on a population that is often inherently counter-cultural is not conducive to long-term recovery for most.
While these groups still have a significant presence they are in decline. Their actual success rate is small compared to the vast number of people with SUD. Generous estimates put it at around 10%. Keep in mind, this is not weighted against all people with SUD. This is usually a number weighted against those who seek treatment as the data is collected by these ATCs. This also is the best they could come up with hard to gather easily manipulated data, along with most people not seeking treatment, well you see how ineffective one solution is.
Many people, because of stigma, and the belief they will have to stop all substance use because of this culture, decline treatment until it is too late. Medications and personal recovery plans that combine behavioral and medical treatment, are very effective at creating recovery for many more people. Many people fear treatment because of this subculture though.
When addressed within the most of the medical community it is often very easy to access MAT, and even Primary Care Doctors will provide some psychiatric medications and MAT. The stigma lies in certain parts of the ATC silo, but bias in behavioral health against addiction treatment is still very common. It is unfortunate that most of the evidence based practice is in regular medicine and behavioral medicine. Easy access to medication for MAT is the new thing, which is very good. Unfortunately, there is still lots of stigma in telling someone about the problem. Many doctors know will cite that they are more than willing to treat, but they need to know there is a problem.
As medications and other modalities have gained hold, this has also been problematic for 12-step modalities. Local groups, as successful people with healthy boundaries, and medications alternative therapies working they discuss things outside of their comfort zone. The members can become rigid or are unable to have a civil discussion. The members fumble for language to get back on track to abstinence, when there is nothing wrong, which disempowers people away for harm reductive measures. They fear that people like this will break their matrix, and I agree. If they do not get guidance from their fellowships, then we should stop making people go, and letting them come in to convert people. They invite people in who most likely are going to confuse their ideology because of their tactics. AA and NA are stuck in a paradox.
There should be more forums for people to be in a community in which a myriad of factors that result in a Substance Use Disorder, can be discussed openly without fear. If abstinence and ideology is what 12-step groups want, they should be able to be safe and not feel threatened. They should be protected. However, they have a paradox. Their way used to be the only way, and they had much power in these circles, but there are many ways now. When they had power, they had control, which led to failure, so we have to change on the whole, but protect their way of thinking and allow for their safe space.
This culture they created has created another dilemma with the opioid epidemic and the need to fight addiction. ATCs are being bypassed by people with SUD because evidence based medicine and therapy has gained a foot hold. This has doubled down on the fundamentalism to keep the safe space where abstinence still has power, in the detoxification silo of care.
This prevents more people from accessing MAT from where they should be accessing it, in treatment for addiction. We will include Cannabis as form of MAT, and the judicial system is ahead of the curve with treatment there too. Some parolees are being told to get their medical cards upon release from prison, this is wonderful and practical. Of all the recreational substances, Cannabis by far has the least behavioral or life-threatening side effects.
Then they go to meetings to deal with what had them in prison, the hard stuff, and they are not accepted. They will get mixed messages, along with the stigma from others that they are not really clean or sober. This is utterly ridiculous, with the risk posed by Opioids of overdose, and Alcohol of chronic disease, this medication should be viewed as just that, or as socially acceptable as nicotine and caffeine. No one likes keeping secrets, and repression and SUD are a bad combination. These fellowships, rather than give a direction of acceptance to their rigid members, prefer to defer to everything as an outside issue, allowing bullying and peer pressure to thrive.
This is where the power of 12-Step groups and Capitalism combine to give the abstinence movement its last stand. ATCs are the Alamo of 12-Step power in clinical settings. Regulation and adherence to clinical and evidence based practice by people that take insurance money and funding from the government is needed. Most of the insurance is provided through Medicaid because most people do not seek treatment until they are at “rock bottom.” This means federal standards on what is needed for programming and evidence based clinical and person centered interventions for treatment.
We know that Capitalism loves government money that is guaranteed. Was it Ralph Nadar who said, of course American capitalisms won’t fail, American Socialism won’t let it. American socialism is a form of reverse socialism that favors the rich, called Capitalism. Detoxification centers have become very good at talking out of both sides of their mouth to get what they want: money. They decline to have the ethics to not let a functional cult drive clinical programming. Employee retention may be a driver of this though. In many of these facilities even the doctors and nurses are in recovery, and will push back on people taking “too much medication.” Do they tell this to diabetics or people with heart disease?
It's akin to requiring someone seeking an abortion to navigate a gauntlet of religious opposition to gain treatment. People are subjected to propaganda claiming that medications are harder to discontinue than fentanyl or are equally harmful. This is all done by culture now, nothing on paper, and they teach people how to document what the insurance company want, not what they do. NA will tell you that they will show you how to get off of medications, through peer pressure and religious conversion by a sponsor who is a financial advisor in NA.
Please get medical advise from someone who is actually a content expert and clinician, a doctor, or a nurse. People don't die from medication withdrawal; they die from relapse, they die from overdose, and alcohol detoxification is still the only one where death is a real possibility without treatment. This would seem like common sense, but as we know the smarter you think you are, the less common sense you have.
The primary benefit for most people with Substance Use Disorder in 12-Step fellowships is the shared experience and sense of identification. However, this is often overshadowed by disempowering interventions and the suppression of individual thought. After the difficult process of achieving initial abstinence, these groups, along with a higher power, take credit, then blame the individual for any subsequent use. This reinforces the disempowering dynamic. While peer support is valuable, it should be coupled with unconditional support for individual choices.
Medications offer the most effective solution and can facilitate sustainable recovery by providing a safer space for the sporadic substance use that often characterizes the initial stages of recovery. Relapse is not a failure, it should be viewed as learning how to identify what not to do. Recovery should be coupled initially with substances that can help manage addiction. Many people will eventually become more abstinent, or not, it does not matter. Addiction and more functionality along with increases to quality of life will occur, and that will create more success for more people with SUD. There are many substances that are beneficial and make behavioral change easier for people with SUD.
Change is happening. The high number of opioid and alcohol-related deaths, coupled with rising methamphetamine use, has exposed the failures of relying on religiosity to treat a complex mental disorder that often intersects with other mental health diagnoses. Alternative peer approaches, such as Buddhist recovery programs, SMART Recovery, Dialectical and Cognitive behavioral therapies, and other new peer support models and therapies, are gaining traction. This may be why after many years, overdose rates are finally decreasing after years of other areas of health care making access to medications easier, and more diversity in the peer recovery culture.
Just like with detoxification centers, people are increasingly bypassing 12-step programs, creating a lack of diversity that makes them particularly unappealing to younger generations for their recruiting efforts. In recent years the vibrant non-religious circle of people on the fringe of 12-Step fellowships out of necessity are gone. The free thinkers have fled these programs to find their own way. This makes even less appeal as these people were an attraction for the aspect of fellowship and identification, and were an initial excellent recruiting platform as they often were the fun ones. Now they have found community elsewhere, often creating an unappealing feeling of rigid repression in many areas of AA and NA.
Historically, these programs have also relied on intense social pressure from treatment facilities, the justice system, and families who have been led to believe that attendance to their meetings is essential for survival. They held great power that is dissipating. The phrases "beaten into submission" and the use of “tough love” was once common. Now, how many die before that happens with our tainted drug supplies. Even then, this coercive tactic was largely ineffective, with many individuals continuing to struggle deemed failures for the rest of their lives. With the emerging peer and clinical resources, and the justice system beginning to lean on evidence based practices rather to 12 step programs, this has also affected attendance and sustainability.
Given the prevalence of substance use, if we accept the 12-step premise that abstinence is the natural human state, then the majority of the world's population would be classified as having a Substance Use Disorder. For most people, substance use remains mild or moderate and allows for continued functionality and no disorder. Addiction is the sole problem we need to deal with as a society, but we can’t because everything is so noisy and loud with conflicting views that this is lost. We should view healthy boundaries and social acceptance among social and casual use as an option. People will succeed in what they are supported in, and many people with Substance Use Disorder will want to continue to use substances. We should not have a culture that reacts to a person with an opioid addiction successfully maintaining a healthy boundary taking Suboxone, Caffeine, and Cannabis. That is a real recovery.
It is the answer to the lack of success of abstinence. We support people in what they want rather than what society wants for them, and work towards functionality in life and quality of life, rather than a perfect ideal. In our current climate, people are often not punished or do not live long enough to reach the point of needing long-term involvement in 12-step programs. This is yet another factor that has led to increased insularity within these groups, relying on past practices and resisting change. Fundamentalism is the end-stage of all cults, and 12-step programs are no exception.
For these organizations to remain relevant, they must embrace two key changes: the complete removal of religious language and the adoption of a subjective definition of "sobriety" or "clean" time. The former is not as relevant anymore, especially with young people, and the latter will eliminate other members being able to determine if someone is “sober” or “clean” and judging them.
This means eliminating non-person-centered language and acknowledging that individuals are the best judges of their own needs and progress. In other words, a wholesale pivot from it’s current position on everything. The question is whether these groups are willing to change, as many members seem more focused on maintaining the established culture and stability of their long-term members than on effectively helping newcomers. The vast networks these organizations have created can be retooled to help millions more people as they have helped in the past in the opinion of this writer, but they need to change with the times.
We have come a long way from the 1930s state-sanctioned programs that sought to "asexualize" and sterilize people with addiction and alcoholism. However, the stigma persists, with many still believing that addiction is a sign of being weak, as they did in the 30s, or that it is hereditary and people are incapable of making their own decisions or are incapable of change. This thinking is the root ideals that created the literature that drives AA and NA.
It is the transmission of cultural beliefs, trauma, and repression of self, that is passed down through generations. Addiction is a symptom of being a human being. We still have a long way to go, and there will be further suffering, but until we embrace new, person-centered approaches to recovery, treatment will continue to be plagued by conflicting messages, some of the most damaging coming from individuals who identify as "alcoholics" or "addicts.”
As care becomes more holistic and integrated, which will take a long time, they will continue to lose relevance. Evidence based practice is that person centered care can be very well facilitated by ethical peer based content experts. In the end, that is what this article is a challenge to. Can we stop validating that the 12-Step path is treatment, but just one of many paths for people with SUD.
There are so many ways to get better that are valid now, there may never be a mass spiritual movement such as this was again. As freedom to be yourself continues to win, we have seen addiction start to taper. Younger people are safer, as harm reduction and education does work. We will struggle with the question of human rights and dignity, and we may go backwards there. There is talk of going back to sanitariums for addiction “treatment” again. When the people who are fascist and judge others on purity and litmus tests get control, they only want to get rid of problems, not solve them.
Where do we go from here. There are so many factors in the drug war, but I wanted to start with one of the most latent elephants in the living room. The false narrative that people with addiction can never manage using a substance again for the rest of their lives, which is as disempowering as it sounds. The only reason this is a question is the perspective and validation of this western spiritual movement practicing religious conversion to abstinence.
What needs to be done more than anything, is to change the culture in Addiction Treatment, end stigma by peers, and focus on the person with SUD. To have the conversations that people will call judgment, it is the intention of this article. If your philosophy cannot be resilient with criticism, then it is flawed. If your society follows the easy answer, then it will not find a solution, only more confusion.
Change starts when the culture that is not working is challenged by others. In the realm of addiction and Substance Use there needs to be more honest conversations. We do not need to placate to one way of thinking, just because at one point this one option which failed for most people from the get go, was validated because our country does not want to tackle substance use in an honest way. Having no health care system, insurance is not health care, is the real blame. Capitalism fixes very little, it just learns to profit off what doesn’t work.
Let’s bring this home. Capitalism, cults, and unethical health care professionals and businessman, have combined to create a fascinating display of ineffective but highly profitable treatment, which also feeds the pool of people to keep running it. How do we get out of this, by creating a unifying culture of people practicing alternative forms of recovery. However, the detoxification system is still the gatekeeper and often the first line of treatment. Their message and even residual power is loud, and disables people from being accepted by a large swath of peers, but that is not a problem for people with SUD to figure out. That is a problem for people that are alcoholics and addicts to figure out.
We can do this through better treatment, in fact if you engage some integrated providers they are actually protective of patients from using 12-Step programs and will educate people honestly about them. We do this through affirmation of people doing better, not telling them they have to be perfect to fit in. We challenge the dominant culture by speaking truth to power.
People and organizations that try to control thought and people will always eventually entropy and fail. For religions it is taking millennia for some, for 12-Step programs their relevance is dwindling and they peaked. It is time people with SUD create their own change. If you go to treatment refuse to go to AA or NA if you do not want to go. If you want meds, ask for them. If they tell you that you have to go to the commitment, or they deny you access to care, sue them. Let’s start there, people with SUD have human rights, and we can use the law to create change.
Thank you for reading my article. Please subscribe, my goal for now is to write an article a week. I will read comments. I do say this up front, if you want to go back and forth gaslighting each other go at it, but we are all 100% right, so just try to leave some constructive ideas for new articles instead. If you try to say I’m making things up, I started being coerced into 12-step programs in 1987 and still go, so save it for another day. There is always more than one perspective, in fact there are around 8 Billion, not including the other animals. If you are reading this, and are sober or clean, that credit is all yours. God did not get you to stop using, your willingness to change your life is what did that. If you succeeded it is because you wanted to change and were supported by people, not because God gave it to you. God is a facilitator, not a doer, and does not need credit for your success, unless your God is vain. In that case, do what you want, but because of the disempowerment I have seen that is an affirmation that I will always make to my friends in abstinence based recovery.