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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.

[This blog was previously published in June 2014]

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

      Yep, right on Doc. I agree. Thx Mac.

    2. Innocent Abroad says:

      There is undoubtedly prejudice on the part of both medical and recovery professionals. And it’s not going to be educated away, either.

      Consider: is addiction an illness, as 12-step programmes maintain? Or is it a symptom, as psychoanalysts tell us? You’d think someone would have found out by now. That they haven’t strongly suggests that the labelling process obscures as much as it reveals.

      Near the heart of the difficulty lies the fact that “recovery” means different things to different people in recovery. Some want abstinence, some abstinence plus fellowship, while others want abstinence plus self-knowledge. And why not? After all, happiness means different things to different people, too.

    3. David Clark says:

      Great blog! Thank you.

      I do wonder sometimes what goes on in the mind of some doctors who are supposed to be providing help. They appear addicted themselves and certainly need a dose of empathy. This no doubts sums it up for some:

      “I think part of it is feeling threatened by a process – recovery – that takes place out of the consulting room or clinic.”

      These doctors need to realise that they do not own healing or treatment, they don’t do the fixing.

      At the same time, I know some great doctors who really make a big difference in the addiction field. We need to keep educating the others.

      Thanks again.

      • djmac says:

        I guess that’s still a message that’s to get through to many professionals – the greatest part of recovery from addiction takes place out of the clinic or surgery. We still place a lot of faith in the prescription alone.

    4. raymond says:

      As a nurse who worked with people with addiction’s problems for years this really resonates. These attitudes permeate professional culture and I was certainly influenced by them. What really helped was going to a workshop run by people from AA and NA who offered insights into how it worked and would answer any questions we had. This allowed all the standard lines about AA from professionals, outlined in the post, to be engaged with and brought me out of my ignorance about the complex ideas underpinning ideas AA etc. From then I was able to engage in much more thoughtful conversations about the fellowships with patients I worked with and accompanied siome to their first meeting to help them with their nerves.

      I would recommend an article by Gregory Bateson about AA which is fascinating and points to its radicalism. This informs part of an epiphany I feel I’ve been on in the last few months about the extent of how the cult of inidivualism central to ideas of the ‘market’ have infects our society, creates so much pathology and then dictiates individually focused responses which as Bateson argues are often doomed to failure.

      The ancient African concept of Ubuntu sums it up: ‘I am because of you’. AA gets it and now I reckon we need something like HA (humans anonymous) to fight against the agonising isolation, alienation and lonliness which underpins so many of the problems our society faces.

      Great post.

      • djmac says:

        I think you highlight the thing that helps turn attitudes around and that’s for professionals to spend time with recovering people and to visit a few recovery meetings. In my experience that usually helps to dissolve the myths.

    5. Ali Roy says:

      Nice blog and spot on in my view. I read this piece in the Guardian on secular salvation myths and I think this has some relevance to the processes of play here too:

      http://www.theguardian.com/commentisfree/belief/2014/nov/21/secular-salvation-myth-distances-us-from-reality

    6. chuck gehrke says:

      Great blog. It’s too bad we (doctors) don’t address addiction and the addict (including alcoholics) the same way we do all other patients and diseases. The only thing to add to your blog is mention of the dismal lack of education and training regarding addiction in medical schools and residencies.

      There has to be continued efforts to spread the word that in fact 12 step programs do have research evidence to support their effectiveness. Chemotherapy benefits lots of cancer patients (but not all) but most everyone with a malignancy is offered it as a treatment option sometime in the course of their illness.

      • djmac says:

        I agree, the evidence base for mutual aid (and social networking) is strong and getting stronger. The problem, as you point out, is that many are not aware of it to any extent, if at all.

    7. Peter Sheath says:

      Thanks for this, great blog. I truly believe that the, “it’s not for everyone”, mantra that seems endemic across treatment services and has become adopted by service user cultures, has become probably the biggest obstacle stopping people accessing the very help that they need. Out of this comes a self perpetuating mythology that in some ways confirms and feeds the, it’s not for everyone mantra and takes on a different dynamic becoming in some circles, “it’s not for anyone.”

      Mark Gilman hits the nail on the head with his, “contempt prior to investigation”, slogan that is so predominant within the cultures of both workers and service users with one of the main consequences being the disparity between harm reduction and recovery ideologists. The strange thing is that when you actually get down to it and open up an authentic dialogue, both are talking about the same things and both want the best possible outcome, whatever that may be, for people using substance misuse services. I feel we still have a distance to go maybe involving us within the abstinence community valuing and accepting that, for most people, recovery will mean medical assistance combined with occasional and dare I say, controlled, use.

      There’s also a lot of work to be done around ensuring that mutual aid, in whatever form, is offered alongside medication as being on par, if not more important than medication, and sold as an essential component of the package of care they are signing up to. Let’s face it services very rarely run short of FP10 scripts, pharmacies never run out of methadone yet it seems alright to run out of meetings lists or not have up to date access to community assets easily available.

      • djmac says:

        Yes, the subtext to ‘it’s not for everyone, can so quickly become ‘it’s not for anyone’. That can show up in practice. The professional who is deciding for his or her clients that ‘no, it’s not for you’ is placing obstacles in the way, not opening up the pathways.

        I also agree that when you get people at the outlying ends of the harm reduction/recovery spectrum together, they do have a lot in common, particularly around wanting what’s best for clients.

        Seeing a higher priority given to getting clients to mutual aid would be welcome. The impact of our clients seeing people in recovery must not be underestimated. It might just surprise colleagues who give it a shot…

    8. Jo says:

      What is the purpose of perpetuating the well-worn notion that staff block access to mutual aid groups? The claim that staff do not promote mutual aid is no longer justified, and the suggestion that staff feel threatened by recovery is, in my experience, woefully outdated. There are variations in the quality of recovery practice, of course, but generally speaking in my experience staff will always encourage participation in mutual aid as a matter of course. Time to update our critique, I think.

      Jo

      • djmac says:

        I only heard yesterday about very negative views to mutual aid; I’m afraid it’s still going on.

      • David Clark says:

        in my experience staff will always encourage participation in mutual aid as a matter of course.

        Sorry Jo, this not the case in my experience and many other people’s experience I know.

        This critique is urgently needed. If we don’t have such critiques then we are doing exactly the same as the professionals who are not acting properly

        • Peter Sheath says:

          David I couldn’t agree with you more. I travel all over the country delivering training, evaluating services and providing consultations. Believe me discussions about mutual aid are almost none existent, most workers don’t really know anything about it and have never been to a meeting and almost no one knows about online support.
          Very rarely do you come across regular meeting attendance of more than 10% of the treatment population, more often than not its around 1%. In all my travels I could probably count on both hands the numbers of people I’ve come across who have physically taken someone to a meeting, used a MA helpline or included a sponsor or such like in treatment planning.
          For me MA should be a standing agenda item in every staff meeting, it should be the same in ongoing supervision and meeting attendance should be a mandatory part of CPD. Rather than stopping the critique we should be turning up the volume

      • Innocent Abroad says:

        I don’t even know when it was true. I only went to AA because professionals (counsellors) in detox and day-care rehab said it was safe to do so – and that was in 1997!

    9. Lawson Main says:

      Loved this article. Just for info we have been running a local church based project for 15 years. I started the project when I was a Detective Sgt. I ended up being Police team leader in a multi-agency team working with Prolific Offenders, helping them combat their addiction. The best outcomes we got were through Christian resources. I retired early 6 years ago to concentrate on what has become a church ministry. I still work closely with local Police, Probation and Drug services where we get most of our referrals from. The Police Sgt who took over my role, who is not a Christian, regularly tells the professionals that they have to remove themselves and their beliefs out of the equation, as it is not about them, but what works for the client. Result = great outcomes, because as Harry Truman said ” Its amazing what you can accomplish if you do not care who gets the credit.” We all celebrate the recovery.

    10. rachel says:

      I think all health care professionals should attend fellowship meetings or conventions … Education and all that … Also very inspiring for most individuals, in or out of Recovery.

    11. Colin says:

      The drugs project I worked in 3 years ago, which was one of the main providers in Bristol, hadn’t a good word to say about 12 step meetings. Hopefully the power is now being taken out of their hands and PHE are making a stronger push for all providers to have it in their tool kit or lose funding. Then you would see the antim providers change their attitudes.

    12. Pedro says:

      I really enjoyed reading this, as someone who has suffered from the effects of substance use from childhood. Through to being someone who has used substances throughout my life (mostly to ease the anxiety I felt & then to block the added on emotional pain caused by the consequences of ingesting) It felt like a never ending situation.

      I was always able to work but my life was exhausting and substance use was my main priority. I was fortunate to be able to gain access to what I needed but I neglected myself physically and it was apparent to many people that I wasn’t looking after myself. I was able to attribute it to over-working and that was enough to keep stigma at bay.

      I was isolating myself to the extent that I would ignore the phone and I was too anxious to attend a wedding, I knew that there were people able to use substances, with little or no apparent negative effects in their lives and this made me even more ashamed of being different and paradoxically determined to try harder to be like them.

      I have no idea what addiction is but I have my own suspicions and theories (like many people do) that it has roots in neurobiological changes caused by exposure to a triggering agent ( Which is still the prefered paradigm today and is heavily favoured by the funders into addiction research) .

      There are also environmental factors such as socio economic conditions and underlying genetic and epigenetic (gene variations that can be triggered under certain conditions, that would otherwise lie dormant). I am also taken aback by how addictive behaviour can mimic and overlap with autism and there seems to be a high number of people who have close relatives with autism at support groups for addiction.

      Eating disorders too share a common overlaps with addiction, either via problematic consumption or abstinence from food and there has also been queries raised about a relationship between anorexia and autism.

      The underlying solution seems to be a therapeutic relationship between “services” and the people who seek them or are referred to them and this takes a lot of listening, “Fellowships” are very much places where people can be listened to and have an opportunity to speak, they can be problematic for some people because of a higher power belief system and a “Patriarchal” structure. “As bill sees it” Also God is referred to the higher power of “our own understanding” and as “Him”.

      This can put a lot of people off (and quite rightly so) but there are many different types of people who attend meetings and they do not buy into a lot of the dogma but come for fellowship and structure and to help others. The origins of the Methadone programmes in the U.S, that were developed by Vincent Dole, Maria Nyswander and Mary Jeanne Kreek were more akin to developing comprehensive community that supported people along AA & CA lines than today’s pharmacy dispensary conditionality policy, that has warnings attached for the rest of society.

      Already, methods what were reserved for less than desirable sections of society, such as drug addicts, asylum seekers and criminals are now being enforced on people who have to claim assistance from the government, whether working or not. Increased supervision and conditionality are being enforced on people who do not have drug problems or have never broken any law.

      Maybe one day there will be a Humans anonymous, where we will be able to come together, in a shared space and talk about social dislocation, who is doing the dislocating and how we can relocate ourselves and the substance will not be centre stage.

      Pedro (Sober and substance free for 10 yrs ADAT)

    13. Jon S says:

      I recently quit AA after 14 years of sobriety having finally mustered the courage to reject the “higher power” thesis.
      I didn’t leave out of choice it was a reaction to being mistreated an a relationship, another fundamental flaw in all 12 step fellowships being their total disregard for safeguarding.
      I was told I’d almost inevitably drink and die if I quit. Happily that hasn’t been the case … yet.

    14. Dole,Nyswander&Kreek. says:

      Good article, As a healthcare professional and once problematic alcohol/substance user, I’ve worked out my own recovery. I am fortunate enough to have a grasp of my own condition in relation to my environment and when I am “recovering” or “backsliding”. Aa helps me to stay sober, because I know that if i take a single drink, I can end up getting into serious situations, which can be life threatening for me and possibly others. However I don’t know what AA is in reality, there are many people who do not believe in God at Aa meetings, they tend to sit quietly and reflect during the meetings and let others get on with their own “recovery”. That may sound selfish and not working a programme but I had the desperation to get to Aa on my own and find a seat. Now this is going to sound controversial but I firmly believe that I cannot take a single substance in the U.K because of the learned behaviours and associations that I have with taking substances but a couple of times a year I will sneak off and get high in a safe and pleasant environment. Addiction is not about the substance, it is about how we react to our environment. The free market driven, neo-liberal quasi authoritarian class divide in the U.K makes it a horrendous place for most people who are not reached a certain level of achievement to safely try and use substances. I know that I can’t use a single substance in the U.K or else I will become addicted again. However I have enough understanding of this to be able to allow myself an indulgence for a limited period of time elsewhere, where the quality is guaranteed and the settings for consumption are safe and enjoyable. I even still go to Aa meetings, because I cannot drink under any circumstances. Addiction is not a single issue with a simple solution, it is a very complex condition and understanding attribution and functionality is paramount for me. For others Aa and programme must be followed but being true to thine own self and helping others is , for me the way forward. Tolerance, support, safe spaces and more health /socially progressive policies and a challenge to our materialistic way of living must be mounted in order to improve quality of life and make the option of constant substance use a lesser alternative.

    15. Andy Reed says:

      Completelyyy agree. 12 step approach isn’t for everyone. It didn’t work for me. I started drinking at a very young age and it took me a very long time and some drastic events to make me realise that i had a problem. When I took that first step to getting better I felt happy again, but I relapsed 4 times, however Im happy to say Im 9 years sober. So dont worry if you relapse! Its okay it happens, but never stop trying. At a young age I left home and I missed my parents so much, but I always got the chance to visit them and with every visit I felt a little less attached every time. Until eventually I did not miss them anymore. I will always love them, but I became independent. And the same is true for alcohol! I hope this helped someone!

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