It's mutual: Clinicians and support groups take steps together to enhance recovery

CrossCurrents

By Helen Buttery

Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford University in California, won’t win any popularity contests among colleagues for saying, “As educated professionals, we tend to look down on everybody.” Yet it was one of the reasons why he found the results of his recent study so gratifying.

The two-year study, published in Alcoholism: Clinical and Experimental Research in 2007, found that individuals being treated for alcohol use issues had higher rates of abstinence when they received both clinical treatment and mutual aid support than cognitive-behavioural therapy alone. The study is challenging academic and clinical naysayers of mutual aid to rethink how they can help clients with alcohol problems, instead of dismissing mutual aid as separate from treatment or as having no scientific backing, as has often been the case.

Wayne Skinner, deputy clinical director of Addictions Programs at the Centre for Addiction and Mental Health in Toronto, says it’s about time the value of mutual aid be acknowledged. “It’s long overdue, but the whole area of mutual aid is being rediscovered by clinicians and it is being given a growing respect,” he says. But why has it taken so long to get to this point?

For one, until relatively recently, there was no proof that mutual aid was effective, no benchmark study to validate the work being done by mutual aid groups. In the alcohol recovery world, Alcoholics Anonymous (AA) is the best known example. In an increasingly medicalized profession, 12-step programs and other forms of mutual aid are often dismissed by clinicians, who insist that providing effective treatment requires special training, says Humphreys. Mutual aid groups like AA, however, don’t claim to provide treatment; rather, they offer support that can prevent relapse once treatment is over.

The value of being able to personally relate to each other’s experiences, as having “been there,” is often an essential part of the healing process for people with addictions, says Humphreys. “You don’t need an advanced degree to work with ‘I feel lonely,’ ‘I need some encouragement,’ ‘I need a hug.’ Often mutual aid groups can meet those needs.”

Humphreys is not alone in his thinking. “Doctors need an acute dose of humility,” says Dr. Graeme Cunningham, director of the Addictions Division at Homewood Health Centre in Guelph, Ontario. He points to two reasons for clinical resistance to working with mutual aid groups – ignorance and arrogance.

However, professional snobbery is not exclusively to blame. The disconnect also has roots in a divergence between the philosophies traditionally espoused by clinicians, who may take a harm reduction approach, and mutual aid, which tends to advocate abstinence. Traditional 12-step programs have been criticized for adhering to the rigid belief that alcoholism is a disease over which its victims are powerless. Critics say this undermines the influence of psychological factors, such as anxiety, and social factors, such as poverty, and disempowers people with alcohol use problems and other addictions. Others criticize 12-step programs, chiefly AA, for being white, religious, male-dominated and cultish.

However, many argue, this is an outdated view of AA. Translated into 28 different languages, AA is found in Tehran, Dehli and San Paolo. Advocates argue that AA is simply a reflection of the people who attend the meetings. For those who still are not satisfied, alternatives to AA have emerged (see “21st Century” sidebar).

Where 12-step programs, particularly AA, have been accused of being too rigid, with no room for personal choice, clinicians have been criticized for being too soft. An abstinence goal is not necessarily a condition of treatment, and harm reduction strategies, aimed at increasing safety while the person continues to drink or drinking in moderation, are options. But experts say that despite these seemingly irreconcilable differences, treatment goals, from abstinence to harm reduction, can be seen as existing on a continuum, which opens the door to co-operation among services that have traditionally been seen as working at odds with one another.

“Increasingly, what has emerged is a more pluralistic perspective, which acknowledges that we need all of these things, and clients need to be offered treatments based on severity and motivation,” says Skinner. In the United States, studies have found that half of those treated for alcohol and other substance use problems will be readmitted to treatment within two to five years. Skinner sees mutual aid as a crucial component of the continuum of care for people who complete formal alcohol treatment. “Treatment has a finite span to it,” he says. “The real challenge for people is living in the real world, and that’s where mutual aid support may become essential.” Mutual aid can be an invaluable support in preventing the relapse so common with alcohol dependence.

Some may consider clinical treatment to be a softer approach, but it often gets people with alcohol problems started on the road towards recovery. “We meet people where they’re at,” explains Cunningham. In recovery himself for more than 20 years, Cunningham knows firsthand how important it is to have services available that are nonjudgmental and accessible. “I’d be dead now if people closed the door,” he says.

More and more, addictions treatment is client-driven, with approaches to care existing on a continuum, or as Cunningham envisions it, an arc. Where people fall on the arc and what services are suitable is determined by many factors. For instance, a person who started drinking after the death of a loved one may require grief counselling. Or a person with both mental illness, such as bipolar disorder, and alcohol dependence may require concurrent treatment, which also includes attending a mutual aid group for people with bipolar disorder.

Where a person falls on the arc can also change over time. A person may not be ready to abstain from alcohol, but may decide later that sobriety is their goal. It also comes down to personality. Some people simply don’t like groups. And there are cases where mutual aid may be detrimental. “We don’t want mutual aid to be a deal breaker to treatment,” says Skinner. He says that it’s better that clients receive some professional treatment than no help. Skinner also says it is important that when treatment providers suggest mutual aid to clients, they must do so in a way that the client feels respected and not confronted.

But is suggestion enough? When clients are merely given information about mutual aid groups, which is the general practice among clinicians, clients don’t seem to follow through. However, a 1981 study in the American Journal of Drug and Alcohol Abuse showed that when clinicians systematically encouraged clients to attend – by phoning the local AA, introducing the client to an AA member, having that AA member offer to meet the client before a meeting and giving a client a reminder the day of the meeting – 100 per cent of clients attended and continued to attend.

But now, more than 25 years after that study, clinicians still are “not doing enough to encourage clients to attend mutual aid pro­grams,” says Humphreys. He says that it’s not rocket science, but simply a matter of dealing with practical matters – Do they have a car to get to the meeting? – and other basic concerns clients might have – At the group, do they have to stand up and talk about their experience?

Humphreys puts himself in his clients’ shoes and tries to address the types of questions or anxieties he himself might have if he were attending a meeting for the first time. “I try to answer all the questions I would have if I were going to an experience that was new and anxiety-provoking,” he says. And if clinicians are not confident in their understanding of mutual aid groups, neither will their clients be.

 

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