Sunday, August 18, 2013

Don't Trust Addiction Treatment Claims About Success Rates or Not Being a 12-Step Program

When you're trying to find a drug or alcohol treatment center for somebody you care about, you'll likely find yourself at a disadvantage. First, the person who needs treatment may attempt to impose conditions on the treatment center you choose and, even when they sound reasonable, some of those objections may be more about "How do I stay out of treatment or find something more akin to a spa than a treatment center" than about trying to find a good fit. Second, when you call treatment centers for information about their programs, you are trusting somebody at the other end of the phone to tell you the truth. Sometimes that happens, but often it does not - you may in fact be talking to somebody who works in more of a sales capacity than an intake capacity. Also, sometimes they'll share information in good faith but the experience will turn out to be quite different. If at all possible, visit a facility and get a sense of its program and stability before writing a check. Please note, even if the center is suggested to you by a facility that has a strong reputation, you should not trust the recommendation - you need to investigate any recommended facility and, if at all possible, visit the facility and see it for yourself.

One claim that many addiction programs make, that they really shouldn't, is a claim of how many people who complete their program remain sober. First, even if accurate (and it won't be) the statistic is going to be highly misleading - if you focus on treating teenagers who smoke marijuana, you're going to have a much higher "success" rate than if you're treating IV drug users. The same is true if you're counseling people who are concerned that they might be using too much alcohol or using too many drugs, coming to you as self-referrals, as opposed to people coming out of a multi-day medical detox who are not even slightly interested in being sober. Second, the definition of sobriety used by the program may be designed to give a misleading picture of the client's sobriety - focused on the "right now". Third, as responses to patient surveys are voluntary many clients who have relapsed either won't be located or won't respond. Fourth, the questions almost never extend to subsequent treatment - the quack program doesn't care if you had four relapses, completed three IOP's and spent 90 days in Hazelden between your graduation and the present, if you're sober they'll count you as a success. Fifth, the definition of what it means to complete a program can render the statistic meaningless.

One program I saw touted an 80% success rate at five years for patients who completed its program, and while it was a good program what they didn't tell you unless you asked was that they defined their program as being five years in duration, with completion meaning that through those five years you attended weekly meetings (free, or should I say, included in the price of the program) at their facility. If you stopped attending, you didn't complete the program. If you lived in another part of the state or country and thus couldn't attend those meetings, you weren't included in the statistic.

But the claim that makes immediately skeptical of a program is when it presents as a front and center part of its marketing, "We're not a 12-step program". Let me be clear: I am not wedded to the twelve step model. Twelve step program have an interesting history, emerging out of a religious self-improvement program and being transformed into a somewhat secular model for addiction support and recovery. A lot of people have difficulty with the notion of turning their will and life over to a higher power, or with making prayer and meditation part of their daily lives, even if you can do both in a largely secular manner. But as one addiction counselor, who himself had struggled with his fit with the twelve-step model, explained to me, "I tell my clients who have difficulty with the steps that if I had something better, I would send them to it instead, but I don't." Part of that is the fact that AA groups are everywhere, while non-12-step support groups remain relatively obscure. Part of AA's success results from primacy but, whether or not its critics choose to admit it, its success depends on people voting with their feet - the addicts in long-term recovery who go back to AA year after year do so because it works for them.

Through experience, 12-step programs implemented some measures that correspond to certain aspects of addiction and recovery. For example, in active addiction the addict's impulse control diminishes - desire and action become unchecked by rational thought. Twelve step programs attempt to interpose an outside reality check on the addict - if you are craving drugs or alcohol, go to a meeting or call your sponsor. As a period of sobriety expands, the internal mechanism between impulse and action can start to rebuild itself. Similarly, the concept of "90 in 90" - doing ninety meetings in your first ninety days of recovery - is reasonably consistent with the amount of time it takes for the addict's impulse control to start to approach normal levels. The social aspect of the group can be reinforcing - you're dealing with people who have been through what you have, or worse, and they want you to succeed in your recovery. They'll also welcome you back if you relapse. The group's sayings and slogans can give you something to think about, even if you reject the larger program.

It's important to recall, however, that although treatment and therapy can incorporate aspects of the twelve-step model, twelve step programs are not therapy. They're structured peer support, coupled with a structured self-improvement program. Twelve step programs are an adjunct to treatment and, while some people achieve and maintain sobriety without any treatment or participation in 12-step or non-12-step support program, many people need the longer-term peer support and accountability. If you find a program that works for you, be it a 12-step program or one of the lesser-known non-12-step alternatives, it makes sense to take full advantage of the program. There's no reason you can't try more than one program, even at the same time, to see what works.

One of the reasons that long-term participants in 12-step programs can be dismissive of the argument, "I tried a twelve-step program and it didn't work for me," or "The twelve steps are nonsense", or "I don't see why I need to completely abstain from alcohol or substance use to be sober," is that they made those same arguments in their own early recovery. Sometimes they made those arguments for a period of years before they finally did what AA demands, surrendering themselves to the program, and that's when it worked. Again, I'm not arguing that 12-step programs can or will work for everybody, and if you're around addicts long enough you'll see unfortunate cases where a person who had achieved many years of recovery ends up relapsing despite seemingly doing everything right, but there is something to the argument that if you surrender to the program it can work for you.

The primary purpose of a marketing hook, "We're not a 12-step program", is to reach people who either are alienated by the very concept of the 12 steps, or people who find them difficult or intimidating. Were the argument intended to reach people interested in science-based recovery, it would put science front and center rather than a rejection of the twelve steps. To the extent that a recovery program can identify addicts who will or will not benefit from a particular treatment modality and channel them into programs and support groups that are likely to work for them, I'm all for it. But, as much as they may protest otherwise, when they flatly reject the 12-step model in toto they are rejecting approaches to treatment that have been documented to work for many people. If you're going to claim to offer science-based treatment of addiction the science should be front and center, not the rejection of a particular approach to treatment.

L.A. Weekly published an in-depth article about a treatment center that claims to reject the 12-step model,
I tell [a person who completed the program] that despite [the proprietor] Prentiss’ denouncements of 12-step programs, I saw residents’ schedules on the wall that indicated optional A.A. meetings.

“When I was there, we did six or seven [A.A.] meetings a week. Two or three in-house and the rest out,” he says. “And they were mandatory. When Chris wrote his book [The Alcoholism and Addiction Cure],that ended. That’s when he decided A.A. was the villain, because he decided he could make a fortune if he just claimed he had found the cure for alcoholism.”

The business executive continues in an upbeat, almost appreciative tone: “Chris has a brilliant scheme that they have cooked up there. He has the perfect sales pitch.” His voice suddenly drops. “I know. I fell into it. It’s a beautiful sales pitch when someone is at the end of their rope.”

When I tell Stuart I couldn’t find any of the success stories Prentiss brags about, he tells me, “People come in there, they fail and nobody can call him on it. He’s got clients with confidentiality agreements to hide behind.”

How did anybody at all get sober, I ask? The answer, says Stuart, is the ironic one: A.A. I remind Stuart just how adamant Prentiss was with me in mocking A.A.

Chris was having trouble filling the beds, and the minute he changed the message, they filled to the brim. He created a cash machine,” Stuart [a person who spent $250,000 on the program] says. “After my stay in ’05, I was invited back as someone early in recovery, and I started talking of all the people I had been there with who had relapsed. And my message was, this is a great place, it’s just not gonna teach you anything about staying sober when you leave.”...

[Dr. Jason Giles, former medical director of the center] repeatedly hedges when asked to talk about Prentiss, but finally says, “The interesting part, I think, is how people are vulnerable to charlatans. I think these rehabs are modern-day quackery.”

Then he lowers his voice to a whisper and adds, “I’ve been in contact with a lot of my former patients from when I was there and the data, the data do not come anywhere near what he is quoting as his [84.4 percent] success rate.”
This came to mind when I saw an invitation to submit questions to the medical director of an addiction treatment center on the New York Times website. The center utilizes the 12-step model, so predicably the critics of the twelve-step approach appeared to denounce it. One in particular was pushing an "education program" as an alternative to treatment, sharing this link.
Outside independent professional research firms have certified a long-term success rate of at least 62% for the St. Jude’s Program. This compares to a success rate in the range of 0-20% for conventional programs.
Let's take a look at an example of that "research".
Clearwater consulted with BRI regarding the specific information needed for fielding. Baldwin [the parent company for the education program] and Clearwater mutually agreed to have Clearwater use Microsoft Access to randomly choose names from a list provided to Clearwater by BRI. After the names were selected, Clearwater accessed BRI’s in ‐ house database containing contact information for each participant in the Jude Thaddeus Program to gather specific information that was copied manully into a spreadsheet. The contact information was loaded into our CATI system and the interviewers began to contact designated individuals and complete interviews.
It catches my attention that no claim is made that BRI provided a complete list of people who have completed the program.
Out of a total of 956 records called, 232 resulted in completed interviews with both parties, giving an overall response rate of 26.17%. Clearwater interviewers “chased” members of the sample who were not reachable at the household or telephone number provided by BRI when someone we contacted could provide us with an updated telephone number.
The low response rate should catch anybody's attention, especially given this note:
Many Guests to whom we were never able to speak with were actually back in rehabilitation again. That information was tracked in the attempt messages, but may be something that should be tracked more quantitatively using a specific disposition or answer choice.
First, it's a misnomer to say "again", given that the program being investigated is an educational program, not a therapeutic program. Second, why exclude from the claimed success rate the percentage of people who could not be surveyed because they were in treatment?

Also, the survey appeared designed to maximize the number of respondents who could claim to be sober,
Have you been sober, not using any illicit drugs or alcohol, for at least the last 30 days?
Self-reporting is a relatively poor method of evaluating sobriety. Some of the people contacted had provided a "corroborator" who was independently asked if the alumnus was sober. When reached, the corroborators indicated a lower level of sobriety than the alumni. Yet the program's official website presents a conspicuous pie graph labeled "62.5% sober for the past 23 years", a claim that they know to be at best highly misleading. As I interpret the graph they are deliberately implying that 62.5% of people who complete their program are verifiably sober after completion, when they know that's anything but the truth.

Going back to the website linked from the New York Times, the statistical argument gets worse,
This compares to a success rate in the range of 0-20% for conventional programs. Data published by Alcoholics Anonymous (A.A.) indicates that its 12 step method has a success rate of no more than 5%. Research also finds that no treatment at all has a success rate of about 30%. This suggests that traditional 12 step programs are less effective than doing nothing.
The "success rate in the range of 0-20% for conventional programs" statistic seems to have been fabricated. No source or context is provided.

In terms of the claim that AA "has a success rate of no more than 5%", if you hear that from any person or entity claiming to be an expert in either addiction treatment or 12-step programs, my suggestion is to run away. The figure being described is a one-year retention rate - how many people who start AA within a particular 12-month period continue to attend meetings. In a survey of people who are attending AA, "35 percent were sober for more than five years; 34 percent were sober from between one and five years; and 31 percent were sober for less than one year. The average time sobriety of members is more than five years." As I indicated earlier, the people who keep going back to AA (and who do the work necessary to pay for meeting space, set up the space, provide coffee, make literature available, etc.) do so because it works for them. If you have to fabricate a 95% failure rate in order to promote your program, the reflection is on your program and not on AA.

According to somebody who reports having twice completed the St. Jude program,
For me, the greatest injustice of all is St. Jude/BRI's CONSTANT slandering of A.A. No, not because I support A.A. (it's a religious cult, with rigid dogma and rituals and little to zero efficacy), but because....well....the St. Jude Thaddeus program IS A.A. I know, weird right? Basically, the St. Jude program is identical to the 12-steps, and its crux (and a "guests" likelihood of success) rests on willingness to "serve others". In A.A. that means make coffee, give away cigs, and **** vulnerable women. At St. Jude it means do dishes, hide candy under your roommate's pillow, and **** vulnerable women. Essentially, instructors act as sponsors who aid in a "guest's" acceptance, surrender (formal surrender prayer said with a sponsor, shit, I mean instructor) a detailing of misdeeds and character flaws, a drafting of an ammends list, and on and on. The only difference? St. Jude insists meetings are unnecessary, it's all about choice, and that after completing the "workbook" you're cured for life!! I just can't believe how much effort they put into distancing themselves from A.A. whilst simultaneously being A.A.
So again we have a program that bashes AA but reportedly adopts or utilizes many of its precepts. The alumnus recognizes the marketing aspect, "St. Jude needs A.A. to exist so they can sell their services based around NOT being A.A.". It's also surprising how some of the most vocally anti-AA treatment centers and programs seem to be owned or operated by people who have no credentials in either behavioral health or addiction treatment.

Somebody who makes a statement along the lines of, "Conventional treatment and 12-step methods of recovery don't work", is being no more true to the facts than somebody who claims "Conventional treatment and 12-step methods of recovery always work". No treatment works for all addicts all of the time, and some treatments that won't work for an addict at one state of addiction or recovery may well be effective when they've reached a different stage in their recovery (or lack thereof).

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