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“It doesn’t work for everyone” – a take on 12-step approaches

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What follows is a guest blog by a GP who gives a personal view on professional perspectives of mutual aid:

“Astonished”

I was astonished the first time I was taken to an NA meeting. I mean, really gobsmacked – you could have knocked me off my seat. The room was full of recovering heroin addicts; something I’d never seen in my 20 years (at that time) in practice. I was both excited – at the possibilities – and ashamed – at the fact that I didn’t know such places existed. It curls my toes to think of it now, but I had not referred my patients to them. That was a while back.

Resistance

ResistanceWhen I began to talk mutual aid with colleagues in practice and with our local addiction psychiatrist, I observed a peculiar thing in many people – a resistance to the concept of self-help at best and downright hostility at worst. I was pretty solidly bamboozled. Nothing I was doing was working hugely well. I mean, methadone was kind of making things a bit better, but I wondered who was benefitting the most; the patient or society. I was being trained in the evidence for reducing the risk of blood borne virus transmission and reducing crime but that helped society as much as it helped the individual. Don’t get me wrong; I prescribe methadone and Suboxone, I’m convinced that harms are reduced, but I’m yet to be convinced that lifelong prescribing is what everyone wants or needs.

Methadone-scriptWhat did the individual want? A normal life. Not to be tied to chemists or prescriptions or be in this relationship with a prescriber where there might be unpleasant consequences if they screwed up. And, lets face it, is the nature of addiction in so many people not to screw up endlessly until they pare away all the things that are important to them? Who wants to be at the mercy of the prescriber as to the ‘consequences’? That’s a top down relationship. As I say, don’t misunderstand, I’m absolutely convinced of the value of replacement therapy, but folk need to know all the options and for that to happen, I too need to know all the options.

I’m not saying this top down thing was what it was like everywhere or all the time, but you heard some horror stories of patients being punished. I remember a colleague making a patient wait a while (a long while) for a prescription because they had missed an appointment, or another forcing the patient to pick the prescription up at a chemist (pharmacy) miles away from where the patient lived as a ‘punishment’ for being late. Then there’s the spectre of forced reductions. Does that still happen I wonder?

“It doesn’t work for everyone”

Once I took a look at the evidence about mutual aid, I wasn’t shy – not a bit of it. I asked colleagues what beefed them about AA and NA. These were the sorts of answers I got:

  • It doesn’t work for everyone (the commonest response)
  • It’s dangerous to come off methadone
  • There’s not a bit of evidence behind it – that’s what the specialists said
  • It’s religious mumbo-jumbo
  • Drug dealing happens at NA meetings
  • Patients don’t like it
  • It’s non professional – “these people” don’t know what they are doing
  • Or another version of that – these places are not regulated
  • Everybody goes to the pub after an AA meeting
  • Nobody stays clean
  • Talking about addiction doesn’t make addiction go away

And so on. It was amazing how many folk had so many rationalisations that effectively acted as barriers to their patients getting to meet other recovering people. Of course, not everyone was like that. Many colleagues were open-minded. There was this addiction consultant who firmly believed AA could do more than he ever could and got so many people there. His name was mentioned by patients a lot of times because of that.

Underlying reasons

Mad man venting steam from earsWhat did I think was behind these opinions and perspectives? A lot of things. Ignorance was one, but lack of understanding of what the evidence says doesn’t explain the emotional response, the degree of resistance that some colleagues have – there’s something else going on there. I think it’s better now but the response, “it doesn’t work for everyone” was like a refrain ten years ago. I began to have to bite my lip when I heard it because it was such a common reply and I started to find it amusing. Paracetamol [Tylenol to American visitors] doesn’t work for everyone who has a headache, but we try it and see if it works, because it works for quite a lot of people. I don’t get the retort “it doesn’t work for everyone” when I talk about paracetamol. Paracetamol doesn’t get folk arguing or getting emotional.

I think part of it is feeling threatened by a process – recovery – that takes place out of the consulting room or clinic. It is non-professional, but instead of being a bad thing, this is actually perfectly healthy and the way it should be. Most of us go into the caring professions to help people, but some of us are threatened at our core when our patients need less of our help than they once did. Those of us who are like this are not very likely to have insight to see it. I think that’s part of what’s going on in some people when mutual aid comes up. It disempowers the professional.

Then there are philosophical or ideological objections. People will argue endlessly about whether the 12-step programme is spiritual or religious. For some, one is as bad as the other! They prefer to turn a blind eye to the atheist and agnostic members of AA because they undermine the firmly held objections. The bottom line is they don’t like it so they don’t think their clients should go. I’m sorry to say that there’s plenty of that around. SMART Recovery might make a difference. Then there are plenty of recovery community things, other than mutual aid, around. It doesn’t have to be like that though. It shouldn’t be like that.

Getting better

Open arms.In any case, the evidence is strong and getting stronger that mutual aid, recovery community resources and connecting to other people in recovery is right at the heart of long term, sustained, healthy recovery. Professional objections to mutual aid might be heard less often these days, but my gut feeling is that the problem has not gone away. At the moment, groups like Narcotics Anonymous and Cocaine Anonymous are exploding in our area. SMART is going from strength to strength. Recovery is visible on the street and in communities. That’s great!

I still wonder though how much effort professionals put in to getting clients along to mutual aid. I do think it’s better than it was, but I think it needs to get a whole lot better still. As I say, mutual aid has an evidence base. It’s true that “It doesn’t work for everyone”, but it works for many and unless someone knows something I don’t, we don’t know who it will work for and who it won’t, so let’s give everyone a shot at it and get as many of our patients or clients connected as we can.

    14 Responses to "“It doesn’t work for everyone” – a take on 12-step approaches"
    1. Anon says:

      Thanks for another interesting read which definitely rings bells for me.
      I wonder whether some of this is in the language – translated into numbers needed to treat and effect size, mutual aid is fantastically effective (not to mention cost effective!). Twelve step facilitation has as good an evidence base as any psychosocial intervention but is virtually unknown as a formal therapy, much less something to be put in a CPD.
      Thanks again for the insights into how genuinely evidence based practice can be trumped by culture and group think.

      • djmac says:

        It’s a good point, how culture, traditional practice and individual practitioner views can end up putting down barriers for clients. Of course, there is also academic resistance to the recovery movement. That’s also interesting…

    2. Vicky S says:

      I really insightful and truthful piece about organisations’ cultural opposition to mutual aid. For me we have no right to refuse a client any information on services or help which may work for them. Yes it doesn’t work for all but like you say, neither does paracetamol. My motto is “horses for courses” – give people the options and sometimes a little encouragement and some of them might just find the answer to their problem and something that works for them. Thanks for the enjoyable
      read.

      • djmac says:

        I’m with you on this. The experience of meeting other recovering people can be a great catalyst to helping people move to the next stage in their recovery and neither organisations, nor individuals should be stopping that happening. In fact the opposite is true I guess; we should be looking for obstacles and removing them.

    3. Great post! I’ll be sharing it next week.

    4. jock says:

      I too so often hear ‘well it is isn’t for everyone’ as if anyone who speaks favorably of 12-step is suggesting that it is.
      Of course it isn’t for everyone, but everyone has the right to find that out for themselves and not have it filtered out of their options for recovery because of a professional’s personal philosophical or political misgivings.

      To narrow a person’s options in this way is the very antithesis of person centered care. Yet it happens so often here in Australia where expressing even the vaguest positive attitude towards 12-step risks you being branded a rabid zero-tolerance anti-harm reductionist.

      • djmac says:

        I think this is key: personal attitudes of professionals should not prevent opportunities for clients. I’m not sure about Australia, but my experience, and the little bit of published evidence from the UK suggest that things are getting better, though we still have a way to go.

    5. Innocent Abroad says:

      Well, alcohol was my drug of choice (so I can’t comment on problems with needles and so on and so forth). I’ve been sober since the back end of 1997, and the foundation stone of all that was the counsellors in detox and day-care rehab who insisted I went to AA meetings.

      My first impression of AA (I was going to meetings in inner West and Central London) was that almost all the other men there were either Irish Catholics or else gay men. (And no, they hardly socialised with each other.) Being neither I encountered a fair bit of underlying resentment and I had to remember that AA attendees are “sick people trying to get well” (there’s an AA in-joke that some members are trying hard and others are just very trying).

      Is it a cult? Well, some of its members will drink again if it is, and others will drink again if it isn’t, but I doubt many drink again because they haven’t worked out whether it is or not. Sounds like a typical addiction/recovery conundrum to me. Carl Jung, whom AA founder Bill Wilson approved of, famously said that there are “Protestant souls” and “Catholic souls” and in my opinion this provides a better framework for the “continuing personal inventory” of Step Ten than anything in AA’s own literature. And with that is needed a lively awareness that Wilson himself wasn’t perfect – he disliked the English, for example!

    6. Anne-Marie Fern says:

      As an addictions professional I saw a lot in the NA meeting I attended that I wasn’t keen on. I definitely think it wouldn’t work for everyone. BUT – I saw loads of people there who it clearly does work for, and I will be urging every single service user to try it out for themselves, and to really try it, not just go to tick it off and say ‘I tried that & it didn’t work’.

      • djmac says:

        Thanks for your comment. I guess the point is that when we start with the premise, ‘it doesn’t work for everyone’ rather than, as you suggest ‘try this and see what you think’ then mutual is less likely to be effective. There are ways to link people up effectively too, which I may get round to writing about some time.

    7. I work at Johns Hopkins Bayview as a peer recovery support specialist. I get a lot of the same attitudes from other professionals,or clinicians because of their belief that because I don’t have a lot of formal education. I definitely get that attitude from other clinicians that my experiance as a recovering addict and someone who is also recovering from a mental illness doesn’t somehow measure up to what they have only read about and not really experienced.

      I always try to keep my mind open to all roads to recovery and have come to realize that recovery is different to everyone. I had to find my own path and most of us will agree that all options should be explored until you find the right option for you. In the meantime professionals should check their egos. They may have years of formal education, but we have years of real experience of dealing with our own recovery, and the recovery of a lot of peers,so at the very least we should listen to each other’s views.

      • djmac says:

        Thanks for the comment and your willingness to share your experience. I really like the recommendation that professionals should check their egos! I dare say we should all do that daily.

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