As Duncan, Miller and Sparks (2004) aptly point out, the vast majority of popular mental health treatments ranging from CBT and DBT to Psychodynamic approaches are all effective and factors such as therapeutic alliance and client factors can have a greater effect on the therapeutic outcome than the type of therapy chosen.
This is not the case at all with addictions treatments because of the fact that the most commonly used addictions treatments are ones which have been proven either ineffective or even harmful in clinical trials; evidence-based effective therapies for addictions exist but are virtually unavailable to clients due to politicking which has long dominated the addictions field.
According to Peele (1989, 1992) 95% of addiction treatment centers in the US use 12 step group therapy. Only one large controlled study of 12 step group therapy has ever been conducted–this is the Brandsma et al (1980) study which compared 12 step group therapy to lay-led Rational Emotive therapy, professionally-led Rational Emotive therapy, Insight-based therapy and a control group. Two thirds of clients assigned to the 12 step condition dropped out. Only one third of clients in four other conditions dropped out. All groups showed improvement including the control group, but the RET and Insight groups showed statistically significantly greater improvement than the control group. Because of the high drop out rate it was impossible to meaningfully compare the 12 step group to the other groups; however a therapeutic modality which leads so many clients to drop out clearly cannot be considered effective. It may even be detrimental; however there have been no studies attempting to measure possible damages done by 12 step group therapy.
Some people cite project MATCH (Project MATCH Research Group 1997) as demonstrating the efficacy of 12 step treatment; however this is not the case. Project MATCH invented something which never existed before called 12 Step Facilitation Therapy (TSF) and compared this to Cognitive Behavioral Therapy and to Motivational Enhancement Therapy (MET). Project MATCH did not have a control group so it actually failed to demonstrate that these therapies were effective at all. However, let us give them the benefit of the doubt since CBT and MET have shown effectiveness in other studies. We still have the problem that 12 Step Facilitation Therapy (TSF) was delivered in one-on-one sessions with a trained counselor which allows for both therapeutic alliance and client factors to play a part. However one-on-one TSF is not available in any treatment center in the US that I am aware of because it costs a lot more money than 12 step group therapy where one counselor can run a group for a whole roomful of clients. But 12 step group therapy creates no therapeutic alliance and moreover quashes client factors by concentrating on convincing clients that they are powerless and must be saved by a higher power. 12 step group therapy is good at creating zealots–but it fails to be better than no treatment at all in helping people to stop addictions.
Much of the confusion about the effectiveness of AA and 12 step group treatment programs lies in the fact that AA and its public relations arm The National Council on Alcoholism have for over half a century conducted a campaign to convince the world that alcoholism is a 100% fatal disease that can only be arrested by attending AA. The real fact is that all addictions have an extremely high rate of spontaneous remission. The NIAAA (2009) says that 75% of alcoholics overcome the addiction on their own without AA or any sort of treatment at all.
The next most common treatment in the US after 12 step group therapy is Synanon-based “tough love” therapy which involves humiliation, degradation, and torture of the client. “Therapy” includes things like forcing adults to dress in diapers, hanging toilet seats around people’s necks, scrubbing bathrooms with a toothbrush, and putting people in the center of a circle where everyone shouts obscenities and insults at them. Not surprisingly this sort of “tough love” makes behavioral problems and addictions worse (Szalavitz, 2006). Many treatment facilities which use 12 step group therapy also incorporate a “tough love” component. Although many of the worst abuses have been outlawed in programs which deal with adults they can still be found in programs which “treat” children.
We know that there are a large number of therapies which are effective in treating addictions including 12 Step Facilitation, CBT, DBT, MET, Psychodynamic, and Harm reduction. All work well and all are subject to the same client and alliance factors discussed in Duncan, Miller and Sparks (2004). The problem is that they are virtually unavailable to clients who are instead forced into ineffective or harmful therapies. That is because these ineffective or harmful approaches are very successful in producing zealots and fanatics. It is too bad that they do not produce cures.
Brandsma JM, Maultsby MC, Welsh RJ. (1980). Outpatient treatment of alcoholism: A review and comparative study. Baltimore: University Park Press.
Duncan BL, Miller SD, Sparks JA. (2004). The Heroic Client: A Revolutionary Way to Improve Effectiveness Through Client-Directed, Outcome-Informed Therapy. Jossey-Bass.
NIAAA (2009). Alcoholism Isn’t What It Used To Be. NIAAA Spectrum. Vol 1, Number 1, p 1-3. http://www.spectrum.niaaa.nih.gov/media/pdf/NIAAA_Spectrum_Sept_09_tagged.pdf
Peele, S. (1989). Diseasing of America. Lexington Books, Lexington, Mass.
Peele, S. (1992). Truth About Addiction and Recovery. Fireside.
Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol. http://www.ncbi.nlm.nih.gov/pubmed/8979210
Szalavitz M. (2006). Help at any cost: how the troubled-teen industry cons parents and hurts kids. Riverhead, New York.
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