Addiction Treatment Can be Harmful
by Tom Horvath, Ph.D., ABPP.
Clients often attempt to choose addiction treatment carefully. Typically, they search for a “program” suitable to their problems, at least as they understand their problems. Unfortunately, most clients are uneducated about addiction. They are not professionals, and the addiction treatment industry and media often present inaccurate information. Consequently, clients can end up in facilities that harm them rather than help them, primarily because in these facilities substandard practices are common (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). Almost daily in our offices at Practical Recovery we hear about what goes wrong in addiction treatment. Here are some examples.
Treatment sessions are not conducted by psychotherapists
By now you must have heard about evidence-based treatments. There are many of them. It seems nearly every treatment facility offers them. Wherever clients go, they would likely be getting at least one of these treatments. What could go wrong?
Unfortunately, the concept of evidence-based psychological (and addiction) treatment can be misleading. Although many medical disorders are now more effectively treated than in the past (e.g., cancer), there is little evidence that psychotherapy is getting more effective (Miller, Hubble, Chow, & Seidel, 2013). Psychotherapy appears to be about as effective as it was before we focused on “evidence-based treatment.” In fact, we may have reached, decades ago, the limit of how effective psychotherapy can be.
Fortunately, psychotherapy didn’t need to improve. When delivered well it is as effective as many medical treatments (Duncan, Miller, Wampold, & Hubble, 2010; O’Brien & McLelland, 1996; U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). But not when it is delivered badly!
The treatment industry needs to focus on providing good (well-conducted, up to standard) psychotherapy. If it is not possible to exceed a standard, then what clients should be looking for is facilities that reach the standard. If someone is offering to provide treatment that is substantially better than anyone else, the claim is almost certainly inaccurate.
When you get medication or surgery, don’t you expect that it will be used in a standard way, and have similar results, wherever you obtain it? Although one surgeon might have somewhat better outcomes or a lower infection rate, nevertheless among surgeons providing a particular surgery we expect similar outcomes (or that surgeon is operating below standard). This same expectation should apply to psychotherapy.
How can that expectation be accomplished? Most practicing psychotherapists understand that they are more important than the specific techniques used, and that the tailoring of any specific therapy to the specific client is critical. Unfortunately, some professionals, and seemingly most in the addiction treatment industry, have become enamored with techniques at the expense of the provider of the techniques. In treatment facilities unlicensed (and possibly even uncertified) counselors provide most of the “treatment.” Some of these counselors may in fact be excellent. However, generally counselors do not have the broad training of licensed psychotherapists. In many cases counselors are simply “in over their heads.” They do not know how to tailor an evidence-based treatment to the individual sitting in front them.
Groups outnumber individual or couples sessions
Most evidence-based treatments have been tested in individual or couples sessions, but most facilities attempt to use them in groups. What was intended as a treatment tailored to one individual or couple becomes something much less. The tailoring can only happen when a well-trained therapist is delivering the treatment one on one, or with a couple.
Because most addiction treatment is based on “program” rather than genuine psychotherapy, it is assumed that any counselor can deliver the program (a kind of curriculum). In fact, good psychotherapy, rather than being based on pre-established goals, is highly respectful of clients and highly responsive to their goals, as well as to what they think, believe, feel, and value (Norcross & Lambert, 2011). This responsiveness requires principles (not curriculum) and individual time (not just time used for case management).
As to “program,” one additional comparison may be helpful. If you have a sudden medical crisis, and decide you need to go to an emergency room (ER), do you call around to find out which ER has the kind of program you need? Or do you show up, and trust that the ER staff will make an evaluation, inform you about options, and move forward from there? We expect ER staffs to be highly trained, and responsive to the myriad problems that might arise when a patient walks through the door. The notion of an ER “program” that could be delivered by anyone with minimal training is ludicrous. But most US addiction treatment is based on “program.”
The groups in addiction treatment facilities, which should have been tailored individual or couples sessions, typically devolve into educational groups, often delivered in a mechanical fashion. Educational groups are at best of minimal value. The scientific evidence about them suggests that they are ineffective (Hester & Miller, 2003). The information in the group may be accurate, but only occasionally does that information address the specific issues of the diverse individuals in the group. It is not hard to see how clients could become defensive and resistant in an understandable effort to protect themselves from a group leader who does not understand them very well but is still pushing ideas on them.
Genuine group therapy can be effective, but most treatment facilities are not actually conducting group psychotherapy. Effective group therapy requires a highly trained leader who focuses on what is happening in the here-and-now of the group, so that participants can learn about themselves by interacting with others and observing themselves in that controlled environment. In addition to a competent leader, the most effective groups need ongoing and consistent membership. Residents in a 30-day rehab are not there long enough to benefit from group therapy at its best, even if the leader knows how to conduct it.
To summarize thus far: What does the Surgeon General think?
The previous concerns are also shared by the Surgeon General, as stated in the first major report on addiction treatment issued by that office. Here are some relevant quotes (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016):
Well-supported scientific evidence shows that behavioral therapies can be effective in treating substance use disorders, but most evidence-based behavioral therapies are often implemented with limited fidelity and are under-used. (p. 4-2)
For evidence-based behavioral therapies to be delivered appropriately, they must be provided by qualified, trained providers. Despite this, many counselors and therapists working in substance use disorder treatment programs have not been trained to provide evidence-based behavioral therapies, and general group counseling remains the major form of behavioral intervention available in most treatment programs. Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems. (p. 4-26)
Group counseling is a standard part of most substance use disorder treatments, but should primarily be used only in conjunction with individual counseling or other forms of individual therapy. (p. 4-26)
Personalized care is not common in the substance use disorder field because many prevention, treatment, and recovery regimens were created as standardized “programs” rather than individualized protocols. (p. 1-24)
Let’s consider additional concerns.
Clients are confronted
Professional staff in many facilities may be more confrontational than supportive. Although in the media “confronting the addict” is suggested as crucial to “breaking through denial,” in fact confrontational techniques are not helpful and may be harmful (White & Miller, 2007). How would you ever know this fact if you only pay attention to the addiction treatment industry and the media? In one review of confrontational techniques, none (0) of 12 studies found that confrontation was helpful (Hester & Miller, 2003). Rather than leading to cooperation with treatment, confrontation is likely to lead to anger and resistance, both of which distract from the goal of getting better. If a client acknowledges that problematic addictive behavior has occurred, and if the client wants life in the future to have no or less problematic addictive behavior, no confrontation is needed. If the client does not have these two foundations (recognition of problems, motivation to change), treatment is likely coerced and should be modified or discontinued, perhaps in favor of motivational interviewing (Miller & Rollnick, 2013), CRAFT (Smith & Meyers, 2004), or harm reduction (Denning & Little, 2012).
Clients are pushed to view addiction as a disease
There is no evidence that adopting the disease model (the idea that “addiction is a disease”) improves outcome. On the contrary, adopting this model (if one also has low coping skills) can lead to worse outcomes (Miller, Westerberg, Harris, & Tonigan, 1996). Both beliefs (addiction is a disease, addiction is something else) should be respected. Fortunately, if the facility is actually delivering tailored evidence-based treatment by adequately trained professionals, the issue of whether addiction is a disease can be ignored. Belief in addiction as a disease is not required for any of these treatments.
Most clients accept that problems exist and that it is time to reduce or overcome them. Adopting a disease perspective might be a short-term solution for dealing with shame and guilt, but better long-term solutions for shame and guilt exist. The client has been using addictive behavior as a short-term solution. Isn’t it time for the client to work on long-term solutions of all types, rather than another short-term one (the disease model)?
An unfortunate aspect of the disease model can be the insistence that the first treatment step should be “primary treatment” in a residential facility. Although medically supervised withdrawal or a brief period of stabilization might usefully occur in a residential facility, in the US the referral to residential treatment seems to be generally based on other motives than the needs of the client (Miller & Hester, 1986).
Treatment is oriented around achieving “real recovery”
If a facility uses the concept of real recovery, then it also views some client improvements as insufficient, or “not real recovery.” Perhaps the common example is opiate replacement (buprenorphine, methadone) or some other medication-assisted change, which is not allowed. Only “abstinence” is real recovery. Ironically, abstinence itself has a variable definition. The client can be abstaining from a range of substances, but still smoking cigarettes, over-eating, gambling to excess, etc.
An alternative perspective is “ideal recovery.” Any step toward improvement is worth supporting, even if someone never gets to ideal recovery (whatever that hypothetical state might consist of). Accepting “progress not perfection” is often termed harm reduction or gradualism. This approach has substantial scientific support (Denning & Little, 2012; U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). Clients, who are already struggling, are further burdened by unsustainable and often arbitrary standards for “real recovery.”
Residential facilities can justifiably require abstinence from substances during the treatment stay. However, outpatient facilities, where most clients are treated, need not have this requirement, and residential facilities can also discuss moderation (Miller & Munoz, 2004) or other harm reduction plans that might take effect after discharge.
What is the impact on clients?
If the client figures out the shortcomings of a specific treatment facility, there is often little recourse (other than leaving, perhaps without a refund). The client may be berated or ridiculed for being resistant and “not working the program.” Even if clients do not fully grasp what is happening, they still know their own significant issues are not being addressed, that their actual progress is not being supported, and that they are not being understood as unique human beings.
From the client’s perspective, if this is treatment, and I can’t adapt to it, perhaps I’m hopeless? The confrontations are often delivered with great confidence. The client is already in doubt about himself or herself (based on all the events that led up to being in treatment). The client ends up even more self-doubting, depressed and pessimistic.
These negative emotions, and the beliefs behind them, are the harms that addiction treatment can cause. Because resolving problematic addictive behavior can often involve several serious attempts at change, if one attempt leaves the client with significant and possibly paralyzing self-doubt, depression and pessimism, future change attempts are likely to be impaired, if they occur at all. In the meantime, it can seem easier to the client simply to return to problematic addictive behavior.
Addiction treatment can be harmful. Be cautious about the treatment you enter or suggest to your loved one. All treatment is not equal. Look for highly trained psychotherapists, a primary focus on tailored individual sessions, no confrontation, acceptance of the client’s point of view about the nature of problematic addictive behavior, and a harm reduction orientation. Be clear about the refund policy before signing any contracts.
Fortunately in most US cities it is possible to find up-to-standard psychotherapists who specialize in treating addiction. If placement in a residential facility is needed, they will make an informed referral. A good place to look for such psychotherapists is the website of the local psychological association. As with finding any psychotherapist, it may take several first visits to find a good match.
The entire US treatment system needs to re-orient itself to the ideas presented here. Many other countries have already made these changes. Until the US does so, addiction treatment needs to be chosen carefully, monitored closely, and withdrawn from quickly if not helpful.
If you or a loved one are in need of treatment, our individualized intensive outpatient program (IIOP) is an alternative to residential rehab that can help. Please give us a call – we are here for you.
References
Denning, P., & Little, J. (2012). Practicing harm reduction psychotherapy: An alternative approach to addictions. New York: Guilford.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (eds.). (2010). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association.
Hester, R. K., & Miller, W. R. (eds). (2003). Handbook of alcoholism approaches: Effective alternatives (3rd ed.). Boston: Allyn & Bacon.
Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2013). The outcome of psychotherapy: Yesterday, today, and tomorrow. Psychotherapy, 50 (1), 88 – 97.
Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment: Who benefits?
American Psychologist, 41, 794-805.
Miller, W. R., & Munoz, R. (2004). Controlling your drinking: Tools to make moderation work for you. New York: Guilford.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Preparing people for change (3rd ed.) New York: Guilford.
Miller, W. R., Westerberg, V. S., Harris, R. J., & Tonigan, J. S. (1996). What predicts relapse? Prospective testing of antecedent models. Addiction, 91(12), 155-172
Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy, 48(1), 4-8.
O’Brien, C.P, McLellan, A.T. (1996). Myths about the treatment of addiction. Lancet, 347, 237–240.
Smith, J. E., & Meyers, R. J. (2004). Motivating substance abusers to enter treatment. New York: Guilford.
U.S. Department of Health and Human Services (HHS), Office of the Surgeon General (2016). Facing addiction in America: The Surgeon General’s report oon alcohol drugs, and health. Washington, DC: HHS
White, W. & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-30.