Dr. Kaskutas is also the author of the research article Alcoholics Anonymous Effectiveness: Faith Meets Science and editor of the book Research on Alcoholics Anonymous and Spirituality in Addiction Recovery. We will be discussing whether abstinence or spirituality are necessary for recovery.
[Start of transcript]
Kenneth: Good evening, everyone and welcome to Addiction Treatments That Work. I'm your host, Kenneth Anderson. Tonight it is September 6 of 2012 and our guest is Dr. Lee Ann Kaskutas. She's doing a big survey, asking people "What Is Recovery?" and she's been a scholar in this field for a long time. She's done a lot of studies on Alcoholics Anonymous, various other approaches to addiction. So we're gonna have some really interesting things to talk about.
Before we start the show, I wanna do a little blurb for our website and our book. Our website is hamsnetwork.org. We are free of charge lay led support group for people who wanna make any positive change in their drinking habits, from safer drinking, to reduced drinking to quitting all together and our book is called How To Change Your Drinking: A Harm Reduction Guide To Alcohol. It's available from Amazon. For more information, go to hamsnetwork.org/book.
Our guest, Dr. Lee Ann Kaskutas is with us right now. We're gonna bring her on.
Lee, how are you doing this evening?
Lee: I'm very pleased to be here. Thank you, Ken.
Ken: Well, I'm really happy to have you here. I wanna start by telling the people a little bit about the survey that's out there online. It's whatisrecovery.org is the URL and the survey is ongoing. So I want the people that listen to this show, after they hear the show to go to the survey website, fill out the survey, give their answers because we're collecting what people think about this. I've done it myself. In fact, it was because I did the survey myself that I discovered Lee here and asked her to be a guest on our show and I want you to tell us a little bit about what the survey is about, what's the content?
Lee: Okay, well the goal of the study is to come up with a definition of recovery from the experience and voices of people who are in some form of recovery, be it methadone maintenance, abstinence based, whatever and the survey, as you said, is on the web. It takes between 12 to 20 minutes to fill out and it covers substance use, issues of spirituality and religion, as they may or may not pertain to your definition of recovery, health, the recovery process itself, feelings, thinking and social environment, and as you know, there are 47 items that reflect those topics and I could maybe read a couple of the items to you--
Ken: Yes, please do.
Lee: --to give the listeners a feel.
So the survey starts out saying, "Recovery is…" and then there is six different items on the first screen that you'll see and the first item says, "Recovery is non-problematic alcohol or drug use," and the respondent filling out the survey has four choices of answer categories. The first one, "definitely belongs in my definition," second one, "somewhat belongs in my definition," the third one and the most unusual one for a survey like this is, "does not belong in my definition, but may belong in other people's definition," and people are to use that category for items that don't exactly belong to their definition, but they know other people who are in recovery and who do believe that that's part of the definition, and the fourth category is, "no, doesn't belong in any definition of recovery," and so a respondent would say to that item, non-problematic alcohol and drug use, maybe they would say doesn't belong in recovery definition, someone who believes in abstinence only might not think that that belongs.
The next item is, "Recovery is no use of alcohol," and again you have those same answer categories. The next one, "No use of non-prescribed drugs." Here's a good one, "No use of tobacco," and the last one in that series, "Recovery is more than just not drinking or using drugs like I used to."
So those are the questions about substance use. Because so many people are in twelve-step recovery, naturally we had to and wanted to reflect their issues and concerns about having spirituality or religion be part of their definition. So we have three items like that: "Recovery is religious in nature," and you can say "definitely belongs in my definition, somewhat belongs, may belong in others but not mine, or doesn't belong in a recovery definition."
The next one, "Spirituality," I'm sorry, "Recovery is spiritual in nature and has nothing to do with religion," and then last, "Physical, recovery is physical and mental in nature and has nothing to do with spirituality or religion," and I could spend more time talking about the other topics if you want me to.
Ken: Yes, please, run through them so that we know what they're like.
Lee: Okay, well one is kind of close to the issue of spirituality and religion is, "Recovery is appreciating that I am part of the universe, something bigger than myself." In health, we ask, "Recovery is taking care of my physical health more than I did before," or "Recovery is taking care of my mental health more than I did before," and we learned in the first phase of developing the survey that we needed to add that phrase "more than I did before," because people were telling us, "Well, you know, isn't taking care of your health sort of what's involved in being a normal human being. It's not about recovery," but when we said, "Taking care of your physical health more than I did before," then it started to resonate.
Another item, "Being able to enjoy life without drinking or using drugs like I used to." One of the harder parts of the survey had to do with the issue of work because, as you know, some people get better jobs once they get into recovery or cut down on their alcohol or drug use. Other people though, quit these stressful jobs that maybe made them drink in the first place and they choose a different path and they have to struggle with, well, I have to support my family, but I don't wanna work as a stockbroker anymore.
So we came up with items like this to try to capture that for our respondents. "Recovery is a balance of living in the present, but not at the expense of the future. Recovery is living a life that contributes to society, to your family or to your betterment. Recovery is living in a way that is consistent with what I feel and think. Recovery is striving to be consistent with my beliefs and values in the work or activities that take up the major part of my time and energy." So that gets at people who might not have a regular job.
We also ask, I don't know if I mentioned this one, "Recovery is more than just not drinking or just not using drugs like I used to," and I'll be interested to know whether people in non-twelve-step programs agree with that statement and we ask later in the survey whether the person is involved or how many meetings that they've gone to that are twelve-step or that are not twelve-step, because I don't know how broad this view is that recovery or reducing your substance use brings with it something more than just paying attention to that substance use. What do you think about that? Or may I even ask you questions?
Ken: Oh, you can ask me anything. You know, I can always take the Fifth Amendment if I don't like the question, but no, I'm always happy. My personal definition, which is for me alone, is to be recovered, actually I don't like the word recovery so much because I don't consider it a disease in the first place, but since these bad habits, which we generally talk about them as bad habits, they are in the DSM and they are kind of officially mental illnesses.
So, if we're going to talk about recovery at all, I would talk about people who are recovered or people who are improved and I would say that a person that no longer meets the DSM criteria for substance dependence is one who's recovered. It's like if you no longer have the symptoms of a cold, of sneezing and coughing, then you're recovered from your cold. You're not always in recovery and just waiting to relapse 'till you get the next cold again.
Lee: And do you think that your definition of being recovered would be including more than just not drinking or using drugs, like in the past, or is it really just the reduction in substance use to your way of thinking?
Ken: Well, my, to me, when it's, when the substance is no longer, substance use is no longer giving rise to the diagnostic criteria, to the symptoms, when you don't have withdrawal, you don't have the tolerance, you're not missing work--it doesn't matter whether you've reduced substance or whether you've quit completely, you know, if you solved the problem, you're over the problem.
Lee: So then you would say it doesn't belong in the recovery definition?
Ken: What doesn't belong?
Lee: That recovery is more than just not drinking or using drugs like you used to.
Ken: Yeah, I would say that does not belong in the definition of recovery from an addiction.
Lee: Or being recovered, let's say, in your case, cause that's the term you prefer to use.
Ken: I would say that does not belong in being recovered from an addiction. On the other hand, it's more complicated than that because so many people find that other issues are entangled in their substance use. You know, they've had depression or anxiety. They've had social phobia and for, well, we'll talk about these first, or they might have financial problems. They might have job problems of having no job or having a job that's too stressful. You mentioned all these, all these outside issues have a huge impact and really they very often need to be addressed before the person can, at least comfortably, you know, control or quit their use of substances. So these things are very much involved.
Lee: Okay, thank you. So the last topic to mention that the survey covers regarding the definition of recovery or being recovered is, "Recovery is being the kind of person that people can count on," and "Recovery is having people around me who know how to get through life without using alcohol or drugs like they used to," and I'll be very curious whether people who use a harm reduction approach and who feel that they're recovered feel about that because there's no literature on the social aspects of being recovered and of having taken a harm reduction approach. I have absolutely no idea whether there are support groups for that or whether there's a need for staying around people of the same ilk if you will; as many people who have an abstinence approach feel is important to them. What do you think about that?
Ken: Well there are a number of support groups for harm reduction. Patt Denning and Jeannie Little in San Francisco and Oakland with the Harm Reduction Therapy Center have pioneered those drop in groups for people that, for harm reduction. I mean, a lot of their clientele have mental illness; they're homeless. They have, they're on the severely addicted end of the spectrum, but these groups give them a place to stabilize and they seem to be very helpful to, you know, help these people improve their lives and of course, our organization, HAMS Harm Reduction, we have our alcohol harm reduction groups which are primarily online. I've been running this organization out of my back pocket with no money forever; so we do, you know, we do what we can that costs the least and you know, you can do online support groups for a very minimal investment. Our chat room costs like $20/month.
Lee: Ah, great. I'm glad to know about those groups. I did know about the San Francisco group and their approach, but I've really only learned at it, about it because of you. So thank you for that.
Ken: Yeah, well many people as I said there are many, many outside issues that impact substance use and it can be very difficult to quit or control the substance use until these issues are resolved. For myself, social issues have been a big one, you know, a lack of socialization, not enough people to talk to. So, you know, I kinda formed my own harm reduction support group so that I would have people to be, you know, socialize with to make, you know, it easier for me to control my substance use.
Lee: So for that item in my study, "Recovery is having people around me who know how to get through life without using alcohol or drugs like they used to," you would say that definitely belongs in your definition, or somewhat?
Ken: Somewhat because not every--
Lee: Somewhat.
Ken: --yeah, not everyone, for me it's very important. Other people have that piece intact. One of the interesting things I've been observing is our book sales. We sell about six to ten books a day, but the number of people joining our support groups are one to two people a day. I think a lot of people are taking our ideas home and applying them and getting their life together without getting involved in a support group. Although some people find that's really essential to get involved in a support group.
Lee: I see. Well, this is an area I would love to study more, because there really isn't literature on how effective these kinds of support groups or these kind of books and approaches to harm reduction are. I mean, I looked at a review paper today in preparing for the interview and there really is not a lot out there. So that's really an important thing to study and I hope that your listeners will be willing to participate in studies like that. Maybe I can write a grant to study that as my next study.
Ken: Well, we would love to be studied. We're crying out to be studied.
Lee: It really needs to be studied. I wrote a grant a couple years ago that failed miserably in grant review. The way it works in my world is we write a grant to the National Institute for Health and then a group reviews it, a group of peer scientists reviews it and give it a score and if you don't get a good score, you don't get funded and I was trying to examine the stability of people in what you might call natural recovery or people who used to have a problem and don't anymore, but they're still drinking and looking at, like over a ten year period, how stable is that for them. How long are they able to hold on to that vs. who people who choose a recovery path that's abstinence based and how stable is that and is there a certain group of people who are able to, over the long haul, stick with a harm reduction approach and other people who can't and who need the abstinence approach and how do we distinguish who those people are and I think if we could do that, that would help therapists a lot when they're confronted with someone who wants help for their drinking. But they didn't fund it.
Ken: It's a very good question. Our approach has always been to say that we support any positive change from safer drinking to reduced drinking to quitting all together. A lot of people that come into our program, they use harm reduction as a stepping stone to get to abstinence. Maybe they don't know that's where they wanna go when they first try, but I would guess about a quarter of the people that enter our program decide to abstain and to remain with our program and, you know, with HAMS, people can, you know, they can take part in other programs at the same time they do HAMS. They can be in SMART Recovery, SOS, Women for Sobriety. Most of our people don't want, they've already had a bad experience with AA before they found us, so that's why they were out searching. So I haven't seen anybody go to AA after our program, but somebody might, but as I said, some of our people that opt for abstinence decide to stay with us. Some decide to do both HAMS and say, SMART or SOS or something and some decide to leave us to go to an abstinence only group because they don't want to be around people talking about how to control their drinking anymore.
Lee: I see, thank you. Well, maybe I can study your group out of my back pocket, like you're running your radio program. [laughter] It's very hard to get these things through review. NIH likes to fund studies of genetics and studies of brain imaging, things like that. It's very hard to get behavioral studies funded and my study of recovery is the only study that we know of that's been funded by NIH and that's why it's so important that the study be successful.
Our goal for the What Is Recovery project is 12,000 completed surveys and the study has been on the web, the survey that is, has been on the web since July 15 and we have 6,400 completed surveys. So we're half way there, but only half way there so I hope that some of your listeners do go to the whatisrecovery.org website and help us reach our goal so we can see how these definitions change based on the kind of recovery path or recovered path that a person has chosen. So I'm really so pleased to be on the program today.
Ken: So you think the survey will be up for a couple more months?
Lee: It'll be up until Halloween. On Halloween, I'm putting on my usual Halloween costume, which is a nun's outfit and I'm gonna relax for probably the first time in four months.
Ken: Okay, my friends on Facebook have already seen me in my Halloween nun's outfit so. Well, not to sidetrack too much.
What kind of steps have you taken to see that the survey gets into lots of different people's hands. I mean, I know twelve-step groups are very tightly networked and, you know, once you pass some info on to them it seems to go through them all and get really spread out really well, quickly, but you know, other things like our organization, it's hard to find. People don't know about it; so what steps have you taken?
Lee: Well, it is hard to find and you know it's not so easy to get to the twelve-step people either because if you're familiar with twelve-steps groups, you know that they have these traditions and one of the traditions is that they have no position on anything that's not AA related. They neither oppose, nor endorse outside issues. So, I get a lot of push back even from my friends in AA who are friends and I say, "Look here's the website for this. Tell your friends about it," and they're not always so comfortable to do that. So they're not so easy to reach either. I mean, we've sent posters to the Alano clubs and we're working with our research partners that are twelve-step oriented like the Betty Ford Center in asking them to get the word out to their alumni, but it's really hard to reach people in twelve-step who haven't been to treatment. There's no lists of those people either. We are advertising about the study at In The Rooms and through Faces & Voices of Recovery.
As for the non-twelve-step approach people, how do we reach them? Well this is, you're right, it's just been a huge effort and we advertise on Craigslist in 140 different locations, on Facebook, Twitter, at churches, at African American churches we're making a special effort to reach minority individuals. As of today, 90% of the people who've filled out the survey are white.
We're working through Native American organizations that aren't necessarily twelve-step based, like White Bison, through mutual aid groups like Women for Sobriety that are not twelve-step, through mutual aid groups that are not spiritual or twelve-step such as LifeRing. We're advertising at September Recovery Month events. At programs that are harm reduction, like Three Principles program in San Jose. NAMA, the National Alliance for Medication Assisted Recovery, is one of our research partners. Easy Does It, which focuses on a holistic approach to the recovery process and the American Association for the Treatment of Opioid Dependence and a lot of word of mouth in programs like this. So far, 13% of our respondents have come from Craigslist and there's a place on the survey where you answer how did you find out about this survey and among the people who said that they found out about this survey from a self-help group, more people found out about the survey from a non-twelve-step self-help group than from a twelve-step self-help group, and so far, 28% of our respondents have not been to treatment and 7% have never been to a twelve-step meeting and among those that have gone to a twelve-step meeting, there are a lot of people who've only gone to a handful of meetings.
So we're having some success with this outreach and I'm hoping that through your listeners, we'll have more success in that area.
Ken: Yeah, I think I saw it first on the LifeRing page, I know I've seen it since all over LinkedIn, which is, that's probably where I get the impression that the information goes very quickly through twelve-step treatment people because it does through the people affiliated with twelve-step treatment programs, the professionals affiliated on LinkedIn seem to really spread these things around quickly.
Have you, and you contacted SMART Recovery and SOS?
Lee: Yes, they're research partners. If you look at our webpage, I mean, at our website, www.whatisrecovery.org, our website has a page that you can select that has our research partners and they're on it as is the National Council on Alcoholism and Drug Dependence, SOS, SMART, Oxford House, Women for Sobriety, of course, I did my dissertation on them so they had to agree, right?
Ken: Mm-hmm.
Lee: And some organizations I don't know if you know about like the National Association for Christian Recovery or Free from Drugs and Alcohol and One in Christ, STONESHOUSE, the Addiction Blog, Soberhood, Friends of Recovery New Hampshire, La Hacienda Treatment Center, the Healing Place of Wake County, the Philadelphia Department of Behavioral Health and Intellectual Disability Services, the California Department of Alcohol and Drug Programs, New York's program. So we're trying, if you have any other ideas, lay 'em on me or have your listeners email me, I'd love advice about how to do a better job of this.
Ken: Well, perhaps we could become a research partner, too.
Lee: Done, all I need is an email from you giving permission and your website and what'll happen when you put on our partner page, if somebody moves their cursor over your name, it will automatically go to your website. So it's a nice way to allow people to find out more about our partners. I'm delighted if you'd be a partner. That's fantastic.
Ken: Well, I'd love to. It would help give credibility to our organization. This is also the first time that we were a sponsor to the National Harm Reduction Conference, too, which is coming up in Portland. So, we're always looking for opportunities. As I said, I started this out of my back pocket.
Lee: I heard that you were speaking along with Amanda Reiman, I think at that conference, if I heard her correctly. I was talking to her today. She'd been on your show recently.
Ken: Yeah, we were on the same panel at the last conference that was in Austin, Texas. My presentation is actually on YouTube and you can kind of see her sitting on the panel with me.
Lee: So you were gonna ask me about marijuana maintenance?
Ken: Yeah, I was just thinking about that. Yeah, some, because well, we've suggested it. Some people have terrible problems with alcohol. They have withdrawal when they drink or they get in fights and various problems and Amanda Reiman, before her, Tod Mikuriya have studied, you know, cannabis substitution for people with alcohol dependence and they found it was quite successful for many people. So is this a form of recovery?
Lee: Well, I would say it's not for me to say. It's for our survey respondents to say, but since you asked me. I would say yes, it is a form and I think that not everybody's gonna agree with that. One of the items on our survey is "Recovery is not replacing one destructive or addictive," I forget how we word it, "behavior with another." So some people are gonna say no to that item, but it seems to me like marijuana, when you have a prescription for it, is a medicine, if you take it as prescribed then you would say, we have an item, "Recovery is no use of non-prescribed drugs and no abuse of prescribed medication." So I would imagine that individuals who are on marijuana maintenance would say that that belongs in their definition. That it definitely belongs. We'll find out from the survey though.
I really don't feel like it's for me to say what recovery is. There was a panel a couple of years ago of scientific experts that was convened and chartered to come up with the definition of recovery and I remember leaving that meeting, I was one of the quote unquote "experts" and thinking it's great that they did this. It's great that they put a stake in the ground to start, that was the first step ever to come up with the definition of recovery 'cause when you think about it, the term is thrown around everywhere and yet there's no definition of it, but I really wanted to come up with a definition based on the experience of people who felt they were in recovery or recovered and that's why I wrote the grant.
Would you like to hear their definition?
Ken: Oh, sure.
Lee: That definition is "Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship," and sobriety was meant to include abstinence from alcohol and all other non-prescribed drugs. So someone who's abstinent from alcohol, but who uses medical marijuana would come under their definition of recovery and so I'm going deeper than their definition on all of these issues of sobriety, personal health and citizenship. Looking under the hood if you will to understand exactly how people who are recovered feel about those issues being part of their definition of recovery.
Ken: Yeah, tobacco and coffee are another couple that are interesting to talk about.
Lee: Yeah, we do ask whether people think recovery is no use of tobacco or not. What do you think about that one?
Ken: Well, I think tobacco is, well, cigarettes in particular are extremely addictive and lots of experts say that they're the hardest addiction to quit. They are mind altering, but they don't generally get people into fights. The problem is if cigarettes were illegal like heroin was, we'd have people in prison for cigarettes and we'd have them being sold on the black market, just like heroin.
So, personally, I quit cigarettes, but I like to have a cigar about once a week. I don't ingest any other form of nicotine. So now I went from being an addicted nicotine user in the form of cigarettes to being a recreational user in the form of an occasional cigar and I don't have to inhale a cigar to get the full effect. So, it's pretty safe health wise. So I did a harm reduction approach for nicotine, but an abstinence approach for cigarettes.
Lee: That's very interesting. So how would you have answered that item, "Recovery is no use of tobacco." Would you say that it may belong in others' definition, but not yours?
Ken: Well, yeah, I would have to say that, because I can't say that recovery has to be no use of something. There's always a possibility of recreational use, non-addictive recreational use. Even things like heroin, you know, we saw that big study with the Vietnam vets that came back and there were so many that were addicted and then seven out of eight, you know, went through spontaneous remission because they weren't in Vietnam anymore and they didn't feel the need to use heroin anymore and a few of them did some chipping, you know, some recreational heroin use afterwards without becoming re-addicted. So it does happen.
Lee: I'm glad to hear that you would use that category. We got a lot of push back from the scientists who were consultants on my study about my including that as one of the options for the response categories, but, you know, most studies, you'll see, you've probably seen lots of surveys where they say, "On a scale from one to seven, with one as strongly disagree all the way to seven, strongly agree," you know, "where do you fall on this?" So there's no room really for saying, "Ah, doesn't belong in my definition, but does belong in others," and when we tested the survey in phase one, we heard from many people that they didn't feel like it was for them to say, "Oh, that doesn't belong in the definition," if they knew people for whom it was important.
Ken: Well, I really like the way the survey was set up. When I took it, that's why I took it and then said, "Who made this? I've gotta find this person and get them on the show."
Lee: Well, we started with 180 items. I bet you're glad that we narrowed it down to 47.
Ken: Well, you have to, because nobody's gonna fill those out.
Lee: Right, that's what we learned. We learned that the hard way.
Ken: It's just long enough now that yeah, you'll get most people to complete it, so.
Lee: Well, thank you. Thank you for giving me the opportunity to talk about that part of my work.
Ken: Well, I thought, I mean, I think the survey is really interesting and I want to encourage the listeners, go to whatisrecovery.org there's a link from the show page here that you can click to get to the survey and take the survey after the show and let's see how many different points of view we can get represented, because I think that's very important, is to get multiple points of view.
I wanna flash back to something you were saying a little bit earlier about, I think it was about recovery being abstinence from a harmful or destructive behavior and that's so subjective as to what one person would think is harmful and destructive and someone else might think very differently about. I mean, some people's, some people view religion as an addiction, or at least extremist religions as an addiction and they view, you know, extremist religions as a harmful and destructive behavior.
Lee: Yeah, the wording on that item, "Recovery is not replacing one destructive dependency," is the way we worded it, "with another," not behavior per se.
Ken: Dependency.
Lee: [talks over] If that helps.
Ken: Well, it's just, I just wanted to, you know, touch base on the way some people might, you know. It's such a matter of personal judgment. I know some people, I used to be one of these people who would consider AA attendance as a destructive dependency.
Lee: It sometimes feels that way, doesn't it?
Ken: Well, I backed off a lot because, well, when I was studying harm reduction. I studied by volunteering in needle exchange. Well, who were my mentors in needle exchange, a lot of people that were teaching me harm reduction were members of Narcotics Anonymous, about half the people I was working with were NA members and about half were active drug users, but nobody had to preach AA during the needle exchange. Well, they knew it was counterproductive. It doesn't work. You have to separate the two. So, you know, many of my mentors being members of twelve-step programs, I had to say, well, you know, there's a lot of sane people in these programs, too. So you know it's really important to respect everyone's right to have their own belief.
Lee: That is so true and you do feel that in a lot of twelve-step meetings and another thing that's interesting about twelve-step is the idea that spirituality or religion or God has to be part of their program because there are a lot of people in those rooms who aren't endorsing a belief in God or the need for religion or even for spirituality, but they don't always talk about it too much, but privately you're learning about it from talking to them at coffee and what not and we're hoping that this survey will be able to give voice to their views as well. It'll be very interesting to see how many of the twelve-step people say that well, recovery is physical and mental in nature and has nothing to do with spirituality or religion. This survey will give them voice, or they may say it doesn't belong in my definition; it does belong in others in terms of it being spiritual in nature. We'll find out.
Ken: Yeah, very often when you are in a twelve-step meeting, it's the people that are the most dogmatic are also the ones that are the most vocal; so it really gives you that impression.
Lee: That's true. I developed an intervention called MAAEZ, M-A-A-E-Z, called Making AA Easier and it's a manualized intervention that treatment programs can use to help people learn what it's gonna be like when they go to AA and so to be forewarned about just what we're talking about now. That there are people who sometimes dominate and sound like they're in charge and we teach them, you know, nobody's in charge and that you don't have to worry about that when you go to a meeting. That you're gonna run into it, okay, get ready, it is gonna happen, but that they don't speak for AA. No one really does.
Ken: Well, no individual does, but AA does have conference approved literature. So that's kind of what defines the dogma.
Lee: That's true.
Ken: So, I mean, for me with my background from this fundamentalist Christian creationist background, who at the age of 13 was reading Darwin and became an atheist evolutionist and, you know, I encountered AA and it was just, it was horrible for me. It was just, well, I wound up drinking more than I ever had before in my life and I just realized I had to get out of this 'cause you know, I nearly died of alcohol withdrawal after my AA experience and I said, you know, I've gotta find a different way to do things.
Lee: That really needs to be studied, but how do you find people like you to be in a survey like that, in order to document the volume of that, you know what I mean?
Ken: Well, you know, people that come to our group, a lot of them, they've had bad experiences. You know, we're not that easy to find. We work as hard as possible to be easy to find, but you know, as I said, you know, twelve-step programs have tens of billions of dollars behind them, you know, to flaunt themselves. When you count all the income that goes to treatment centers and everything and you know, I funded my program by sweeping out a church on the weekends.
So, but I mean, we have fairly decent visibility on the web, even with the handicap, 'cause I wrote a lot of articles. So, Google likes your website if it has a lot of good content that's original on it. So, yeah, quite a few people find our program and they're out there looking because they found AA either unhelpful or damaging or something that they could never even consider approaching. So, yeah, in a group like mine, or in a group like Moderation Management, you also see a lot of people, in SMART Recovery, too, a lot of people, 'cause they've already tried the better known one and then they, you know, have to find something else.
Lee: Well, you know, there is a very high dropout rate and you know that from my paper that I think you read in preparation for our show, that "AA Effectiveness: Faith Meets Science", that, you know, the majority of people do drop out.
Ken: Yeah, that's interesting and as I learned myself, the 5% retention rate is a bit of a myth. It's actually due to a misreading of that paper about the tri-annual surveys, which I put a copy of that on our website, but then I analyzed in and finally said, well, wait a minute, these 5% are the people that they are in their 12 month of participation. They're not the ones left after 12 months, but it is a fairly high dropout rate and something like 25% remain or 15-25%.
Lee: Well, we use the one-third rule.
Ken: Use the one-third?
Lee: You know, that if you're in AA meeting and you look to your left and you look to your right, one of three of you will be here a year later.
Ken: Okay, yeah, I was just looking at another paper, like a couple days ago. It's on the AA history site and their number was of people that go to one meeting at least, one meeting, the number that will stay is about one quarter, cause a lot of people don't ever go back after the first one. So that was the numbers they were coming up with. They were actually saying that people that go, that take the steps seriously, about half stay. So, well there is a lot of that out there. I'm not sure how well documented the paper is, but it's not from a peer reviewed scientific journal. It's from an AA history website.
Lee: Well, my research shows about that one-third dropout rate and it shows, I've looked at attendance over like a seven year period and we have, and how people sort themselves into attendance over time and you have a group that really never gets into it and that's the largest group; and then you have a group that gets real into it early on and goes to a ton of meetings and stays at that level for almost seven years and then another group just like them, they go to a ton of meetings in the beginning, but then they decline their meeting attendance and then there's a fourth group that never goes to a lot of meetings, but who stays at a stable level of attendance, and if you look at the abstinence rates, and when you're studying AA, that's the logical thing to look at as your outcome of interest if you will. The abstinence rates don't exactly track like you'd think they'd do. The people in the group that don't really go very much at all, a high proportion of them are abstinent and 20% of those who drop out and don't go ever again or who never even went hardly at all, 20% of them are abstinent seven years later, you know, and what's that about.
Ken: Well, that's not so surprising, you know, if we actually look at the NESARC, the National Epidemiological Survey of Alcohol Related Conditions, I finally memorized that whole mouthful and we found in the NESARC, you know, after 20 years, three-fourths of people are recovered from their alcohol dependence and out of those that recovered, three-fourths of them did it without AA and without treatment, they did it on their own.
Lee: Yeah, yep.
Ken: So really spontaneous remission, natural recovery is the normal outcome of addiction--
Lee: And it so has not been studied.
Ken: Yeah, definitely not. In fact, it's been, I mean, there's been a huge amount of PR done by treatment centers in particular to say, you know, if you don't come to our treatment center and get our twelve-step treatment, you're going to die.
Lee: Yeah.
Ken: You know, that's what, so again, the public is not really aware that this is the norm. To me, the whole purpose of addiction treatment or addiction self-help groups, mutual support groups, the whole thing is to support natural recovery, to speed it along and, you know, to help it go better.
Lee: Yeah, when my grant was reviewed, the one that enabled me to do the What Is Recovery study, I have to give credit to the grant reviewers, because one of the grant reviewers said, you know, make sure that you go after people in what we're talking about now, people who are in natural recovery, because it's such an understudied area. I mean, there's actually not that much research about AA either, as you know, from my research paper, "Faith Meets Science." There are more studies of it though than of natural recovery, most definitely.
Ken: Yeah, it's really difficult to study, first it's really difficult to study any self-help group. You can't, you know, get randomized controlled trials of a self-help group because people are generally self-referred. If they don't wanna go, they're not gonna go, unless, you know, you hold the threat of jail over their heads or something like that and that doesn't really work either, but it's something really difficult to study, you know, and it doesn't matter if it's AA, or SMART Recovery or HAMS or Moderation Management, they're all equally difficult by their very nature.
You know, I say, I can't tell people anything scientifically from, you know, just observing the people that come to HAMS, the people that stick around and get involved, because you know, there's no way to track the people that don't get involved or the people that never come.
Lee: That's exactly right. Well, you know from my paper that there have been some randomized clinical trials that did try randomizing people to AA and what happens in those studies and what makes the results hard to interpret because of what happens in those studies, is that, so let's say that you're assigning half the people in your study to go to a hospital based treatment and half of them to go to AA. So you can't force the people who are randomized to go to AA, you can't force them to go, but you also can't stop the people in a hospital program from going to AA; so that muddies the comparison.
Ken: Yeah, the Brandsma study was one that you mentioned and that's an interesting one cause it's not really a study of AA per se, so much as it is of twelve-step treatment programs--the more traditional Minnesota Model compared to a control group and then some Rational Emotive Therapy groups, which were Rational Emotive treatment groups; so they were actually done in treatment, and you know one of the interesting things to me was that at the one year follow up, almost all the statistically significant differences between the control group and the treated groups had disappeared. There was only one left that was statistically significant and, you know, the problem is not that the treatment starts wearing off, but the control group always gets better. Darn them. They don't get worse. Their disease doesn't progress. They all start getting better with no treatment.
Lee: Yeah, it's just like I told you about the paper where I looked at people over seven years and most of them didn't go to AA and 20% of them were abstinent. Darn it anyway.
Another interesting study in that paper is the big study that was funded by NIH called Project MATCH. Your listeners might be interested in that one because it compared a twelve-step facilitation approach, which was just the kind of treatment where you're told to go to AA and that's pretty much what the treatment is and it was compared to a cognitive behavioral therapy and the third condition was a motivational enhancement that was not the heavy handed you gotta go to AA. You know, it was more, let me find out where you are with your drinking and let's work with you to do something about that and what they found in that study is when they looked at reduction in problems over time from the beginning of the study to a year and a half later, they didn't find any differences in those three treatments and they really thought they were gonna find certain groups that did better in one treatment, like the people that weren't that motivated, they had hypothesized that those people would do better in motivational interviewing and they thought that the people that were believers in God, high on spirituality, would do better in the twelve-step and the people that had problems with their drinking triggers, would do better in the cognitive behavioral therapy because they would learn about relapse prevention, but none of those matches panned out, to the chagrin of NIH because a lot of money went into the study.
So the take home message is kind of, well, you would think that matching would work and there's a certain kind of somebody who would do better in a certain kind of treatment, but so far we haven't been able to drill down to understand that very well.
Ken: You know, there's somethings about Project MATCH that bothered me. We did have Joe Nowinski on the show a few months ago, who did the 12, he designed the twelve-step facilitation therapy module and we talked about this in some detail, but the twelve-step facilitation therapy module from Project Match is so far removed from anything that you see in any twelve-step treatment center that's available in the U.S., that it really doesn't inform you.
One of the things was all the twelve-steps facilitation therapy was delivered one on one by a trained therapist--
Lee: Right, right.
Ken: --whereas when you check into treatment, you get one counselor who does a group of 40-50 people. You never get a one on one discussion with them, 'cause it's really cheap to do treatment that way and the whole thing is to make money. So that's one huge difference.
The other huge difference and I mean, I went through the twelve-step treatment program at St. Joseph's Hospital in St. Paul, Minnesota, so it was a very typical Minnesota model. The other thing is that anyone that relapses is kicked out; whereas in Project MATCH, if you relapsed you were suppose to discuss it with the therapist, you were supposed to be proud of the abstinence days that you had and not beat up yourself up to much. It was very much out of Alan Marlatt's relapse prevention, so it was very different from, you know, the treatment programs that are out there. To me, you know, if someone says we're twelve-step, Project MATCH proved that we are evidence based, you know, they're just full of it.
Lee: Well, my MAAEZ manual is a little bit different than that, making AA easier. My twelve-step facilitation is different than the Nowinski approach in that it is group oriented and it's not, it doesn't have to be led by anyone with a Master's degree or a Ph.D. in psychology. It can be led by anyone who's familiar with twelve-step groups and knows how to lead groups and rather than focusing on the philosophy of AA, it really focuses on the people you're going to encounter in AA, but I agree with you that even that is not, I mean, only about 100 treatment programs in the country have adapted my manual to their treatment and we know that there's more than 100 treatment programs in the U.S.
Ken: Yeah, it seems like the standard is still the same as it always was. Do big groups to make it cheap and if they relapse, kick 'em out. That still seems to be standard operating procedure almost everywhere.
Lee: Well, some places are starting to change that though. Kaiser, for example, Kaiser Permanente has a wonderful new approach that they've been using for the last several years where they're having these groups for people that are not gonna quit drinking and they're not thrown out if they decide not to quit drinking and some of those people go onto the abstinence programs that Kaiser offers and others don't. Others just stay in that track, if you will. So there is some hope on that horizon I think.
Ken: I think some have changed. I'd like to see a lot more, you know, I'd like to see some more pressure. You know, I'd like to see something, the equivalent of an FDA for addiction treatment, you know, to hold people to some standards of quality because there is no standard of quality. We mentioned briefly, I think it was before the show, some of the teenage treatment centers which are just torture. They just torture people and make them worse, things like Straight, Incorporated and WWASP, the Worldwide Association of Specialty Programs. These are still operating although most of them have gone, you know, off shore into, you know, places like the Philippines or something, but or Mexico. If some treatment center wants to send, ship your teenager off to a foreign country, don't let them do it.
Lee: Well those are pretty desperate measures, aren't they? The parents must be very desperate to send their children there.
Ken: Well, the parents get talked into it because, you know, they've got really slick salesman, you know, selling these things and they get testimonials from, because of trauma bonding and basically Stockholm Syndrome, you know, even though they're actually more detrimental than doing nothing at all.
Lee: Well, they need to be studied, too. A lot of work out there for us researchers then.
Ken: Yes, there is. Well, we're getting off track now. Project MATCH I want to go back to. The other thing that I was really bothered by with Project MATCH is that they did not have a control group.
Lee: Well, that's a big criticism. Everybody has that criticism, but you know the dirty secret is that the TSF was the control group. Many people involved in that study thought that was gonna be like a control group because it was nothing to their way of thinking because you gotta remember that, you know, the treatment world thinks that people need to go to treatment and AA. So the idea that just going to AA could possibly be as helpful as going to a cognitive behavioral therapist or going to motivational enhancement training, you know, that was anathema to them and so, they really didn't expect that the twelve-step facilitation group would do as good as it did.
Ken: Well, that's interesting. Of course, it was really different than standard twelve-step treatment. It had all these, it's like they loaded the dice to make it perform much better than the old Minnesota model would.
Lee: I don't know that the outcomes would be any different in a Minnesota model program. I mean, we see a lot of consistency across these with the success rate. They're not that high. They're high-ish, you know, but they're not, it's certainly not in the 80's or 90's percent success.
Ken: Yeah, but what we saw in Brandsma that was really interesting was that two-thirds of the twelve-step group dropped out of treatment and only one-third of all the other groups dropped out of treatment so it was definitely off putting to people and they didn't want to be involved in it. So, that's definitely a statistically significant difference.
You know, I read Joe Nowinski's manual and I said, boy, if they'd given me treatment like this it would have been really good, compared to the crappy treatment that I did get.
Lee: Well, they're trying to get treatment programs to be a little bit different and use these manual based treatments like Nowinski's twelve-step facilitation or my MAAEZ manual, but you know, therapists like to do what they're comfortable doing and what they believe has been successful in the past and when you give them a manual and say follow this, it's not so easy for them to integrate that into treatment and like you say, it's groups anyway so, how do you cram what Nowinski wanted to do one on one into the group format. You know, it comes down to money at some level. So we really need a group format twelve-step facilitation intervention, you know, like MAAEZ or a group format one like Nowinski's but for group format.
Ken: Well, there's also some evidence that one on one in and of itself gives better outcomes. I can't quote papers off the top of my head but there is, I think there's some evidence to this. I know that I went through two treatments. The first one, my therapist was kind of a rebel and talked to me a lot one on one even though they weren't supposed to and it was very useful. Actually, we developed a good relationship and it was supportive even after I left. I could call up and say, you know, let me talk to Mimi and it was very helpful to have that one on one relationship.
Lee: Well, I think that's really why AA works, when you get down to it. I mean, I've done studies that looked at the effectiveness of AA and for those for whom it was effective, what was the mechanism of action that explained why it was effective and those are called mediator analyses in the scientific jargon and the variable that comes up in every study that ever, ever, ever looked at that is having at least one person in your social network who you can talk to about your drinking and who has themselves been there. That one on one connection is, seems to be what matters, and that's kinda what you're talking about in a way, that your therapist connected with you.
Ken: Well, I think we're running out of time. We've run almost the whole hour.
Lee: No. Have we really? Oh this has been fun, thank you.
Ken: Yes. So everyone that's listening, we wanna send you once again to take the survey, it is whatisrecovery.org. There's a link from the show site and thank you very much Lee Ann Kaskutas for being our guest this evening.
Lee: You're very welcome. Thank you. Bye.
Ken: Bye. Everyone come back next week. Our guest will be Dr. Lala Straussner who is, she's with the NYU Silver School of Social Work. She supervises the addiction treatment training programs there. It should be very interesting. We're gonna be talking about women and minorities and tailoring addiction treatment to specialized groups. So we'll see you all then and good night.
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