Some Old With the New

Although addiction treatment agencies increasingly are incorporating nontraditional or alternative approaches in their practices, from drug therapy to acupuncture to yoga, the traditional 12-Step approach is not being abandoned in the least.

Even when practitioners turn to newer treatment modalities, they almost without fail provide clients with information on the decades-old 12-Step approach to help them deal with their addictions and maintain sobriety. The reason, according to addiction professionals, lies in accumulating evidence-based research supporting the effectiveness of the 12-Step process as well as its value in enhancing other treatment strategies.

The 12-Step approach is clearly a brightly colored staple in the spectrum of treatment options available to today's providers, according to many practitioners. The McLean Hospital Alcohol and Drug Abuse Treatment Program (ADATP) in Belmont, Massachusetts, as well as McLean's new residential treatment facility in substance abuse, the McLean Center at Fernside in the community of Princeton (the latter officially opened last summer), offers a prime example of an operation committed to providing that spectrum of options, according to Shelly Greenfield, MD, MPH, associate clinical director of ADATP. “We provide a full continuum of care, including both on-site and off-site programs,” says Greenfield. “And we take an evidence-based approach to addiction treatment, which, of course, recognizes the value of the 12-Step method.”

The McLean ADATP's basic tenet toward addiction, explains Greenfield, is to provide treatment based on research and empirically tested methods. “We try to find the latest methods that have been shown to be effective and then individually tailor the treatments according to the individual's clinical needs,” she says. That can include medication therapy as well as psychiatric treatment and behavioral therapy, she notes. Center programs use both cognitive-behavioral therapy and dialectical behavioral therapy techniques, and incorporate group treatment and families into the client's care.

The treatment approach, therefore, isn't simply a reflection of the 12-Step method, but what Greenfield calls “12-Step facilitation,” which involves explaining to clients the method's importance in recovery and relapse prevention.

McLean's incorporation of other treatment modalities includes aggressive use of medication options. For example, says Greenfield, if either an inpatient or outpatient is “ready to launch herself into recovery” from opiate addiction, the program might attempt to detoxify the patient by administering a course of Suboxone, one of the brand-name formulations of buprenorphine. Some patients in the Suboxone program may complete a short detox program while an inpatient. Others might need a longer stabilization period and be referred to the outpatient Suboxone treatment clinic.

The program also uses the medications naltrexone and acamprosate for treatment of alcohol dependence, and continues to look for other effective medication options, says Greenfield. However, she adds, there's a limit to what medication can do. The program also treats co-occurring psychiatric conditions such as depression, bipolar disorder, and post-traumatic stress disorder (PTSD) in patients with addictions; in these cases, both psychotherapy and medication may be utilized. “Most of the literature and studies show that if those [mental health] disorders are appropriately treated, people have a better chance of staying sober,” Greenfield says.

When it comes to treating disorders with approaches other than 12-Step, a treatment technique that continues to gain traction among addiction treatment professionals is Motivational Interview-ing, a client-centered approach that generally helps individuals explore and resolve ambivalence. This approach allows clinicians to “get to issues more quickly” and enables clients to see those issues more clearly, explains Shirley Beckett Mikell, deputy executive director of NAADAC, The Association for Addiction Professionals. “It also provides a faster connector, and builds the security of the client with the clinician more quickly than some other approaches,” Mikell says.

But, she adds, that process may not be entirely comfortable for the client. “Therapy never is comfortable,” she says, regardless of what techniques are employed.

Eclectic approaches

Recognizing the potential shortcomings inherent in any therapeutic technique, practitioners at the English Mountain Recovery program in the Smoky Mountains of east Tennessee are employing a more eclectic, holistic approach without abandoning the bedrock 12-Step technique, according to David Cunningham, LADAC, NCAC I, clinical outreach director.

“I have found that there is an ongoing evolution at treatment facilities in becoming more open-minded to other scientific, evidence-based approaches that are useful in recovery,” Cunningham says. Clients at the 56-bed English Mountain Recovery may be exposed to a variety of counseling therapies as well as to alternative therapies such as acupuncture, yoga, nutritional therapy, and equine-assisted therapy—all enhanced by the tranquility of the facility's setting.

“At English Mountain,” Cunningham explains, “we're branching out and implementing some additional treatment models but we're not abandoning the 12-Step; it's been proven to work.” English Mountain is a 90-day program that is open to innovative strategies to help the client achieve long-term sobriety. Still, its officials write in the facility's statement of philosophy, “We strongly believe in the principles and philosophy embodied in the 12-Step programs. We find this approach first outlined in 1935 offers the most responsible path to recovery for the chemically dependent person.”

Another example of a facility using a diverse approach is Timberline Knolls, located in the Chicago suburb of Lemont, Illinois; the facility opened earlier this year as a residential center exclusively for young women with addiction and emotional disorders. The center's practical approach is showing positive early results, according to medical director Sheldon Miller, MD, and assistant medical director Kimberly Dennis, MD.

Many clients arrive in treatment with multiple psychiatric diagnoses as well as chemical addictions or eating disorders, Miller says. Specific treatment is needed for all of these disorders, since it is not uncommon for eating disorders—which are not always active when someone is in a chemical dependence stage—to surface during the early period of abstinence from drugs, Dennis adds.

To address these issues, the center offers individual, group, and family therapy, Miller says. Sessions may occur with families present or by means of electronic conferencing if family members don't live in the Chicago area. Center staff members seek to provide families with information on the medical model of addiction, Dennis notes. “Many families are not aware that there is not anyone to blame for the disease,” she explains. Clients also receive information on groups such as Alcoholics Anonymous and Overeaters Anonymous in their communities before they leave the center, to give them a tool in relapse prevention, Dennis says.

“We're focused on using whatever therapy we can find support for in the literature,” Miller says.

Backing for 12-Step

The 12-Step process has staunch defenders who continue to put an imprint on some of the newest treatment facilities in the marketplace. Frank Lisnow, MEd, MAC, executive director of the Center for Dependency, Addiction and Rehabilita-tion (CeDAR), part of the University of Colorado Hospital, strongly believes that “the 12-Step modality still works the best.”

Lisnow adds, referring to the approach employed at his 13-month-old facility, “We use medication therapy, psychiatric and behavioral therapies as well as many other modalities to buttress the patient's ability and willingness to be involved in 12-Step programs.”

That belief has been bolstered by research carried out to determine why the approach works. Research in neuroscience has indicated that 12-Step work provides a method to facilitate the brain's ability to repair itself, Lisnow says. Promoting a sense of responsibility, community, spirituality, and well-being —essential tenets of the 12-Step approach—actually helps the recovery process within the brain as well as the body, he notes.

“There has been anecdotal evidence since 1935 when AA started the 12-Step program,” Lisnow says. “Now we have evidence-based data available that show that the program does work. I think the program has been reinforced.”

He adds, “We take pride in using a 12-Step based program. We work on issues so that a person can be well-introduced into the program, because it is good treatment.”

Randy Haveson, founder of The HERO House (the acronym stands for Higher Education Recovery Option) residential program near Atlanta, is a proponent of 12-Step approaches in the effort to help college students maintain sobriety. “One of our rules is that you have to attend at least four 12-Step meetings per week, have a sponsor, and be actively working the Steps,” Haveson explains.

The HERO House essentially adapts the traditional 12-Step approach to the student. Students in the program live with other students. “We want like-mindedness,” explains Haveson. “We're putting them in a community where they're doing the same things. They study together and do homework together. We want to give them as much normal college involvement as we can, but they must realize that they are addicted and in recovery.”

Today's addiction professionals have been exposed to a wider array of treatment modalities in their education and clinical experience, and many are choosing to incorporate them in their practices. The 12-Step approach is just one of many alternatives now available to the treatment community, notes NAADAC's Mikell. “More people are aware of different approaches, and they are not as hesitant to use them as they once might have been,” she says.

While there is more clinical research out there than before to support the effectiveness of the 12-Step process, that doesn't necessarily explain its continued and strong use in full, according to Mikell. The pendulum simply may be swinging back toward a more pragmatic approach, she says, representing an attitude shift among professionals.

“A few years ago, more people were pulling away from the 12-Step approach,” Mikell says. “Now they again see its usefulness, so they're reincorporating it into their treatment regimen.”