Clinical Pathways to Recovery
Over the past two weeks we have discussed the Self-Managed Pathway to Recovery and the Non-clinical Pathway to Recovery. We started with a discussion of how Secretary Kennedy’s promotion of less well known and used approaches, such as he has with Therapeutic Communities, too often tend to suppress advances in evidence based progress in treatments across an array of disease states. We thought, also, that a review of treatment approaches would be an important part of creating greater understanding of substance use disorder. Likely most Americans would know little beyond residential treatment programs (“rehab”) and twelve step programs such as Alcoholics Anonymous.
As we enter into discussion of the Clinical Pathway, we should correct the impression that Self-Managed approaches and Non-clinical Approaches are, in fact, non-clinical in our view. As we saw in the Self-Managed Pathway, it is increasingly common to find evidenced-based elements such as in SMART Recovery. So-called Non-clinical Pathways that were once strictly twelve-step based now often employ credentialed individuals, contract with physicians, nurses and psychologists, and the twelve step approaches are increasingly thought of and applied in clinical terms.
The Clinical Pathway is thought of as such since it increasingly relies on MDs including Psychiatrists, advanced practice nurses, and Ph.D. and MA/MS prepared Clinical Psychologists who bring with them a reliance on evidenced based treatment per their training. They also bring capacity and an industry-wide reliance on pharmaceuticals. In fact, this pathway can be roughly divided into two approaches. Pharmacotherapy deploys pharmaceuticals either as stand-alone treatment or more often in combination with another therapeutic approach. Today we will focus on more traditional Psychotherapy, which is most popularly based in cognitive behavioral therapy (CBT) informally called talk therapy.
Twelve-Step Facilitation originates from the Minnesota Model of addiction treatment first created in a Minnesota hospital in the 1950s. Typically a team of clinicians and non-clinicians (likely to identify as in recovery themselves) provide care management centered on engaging patients with 12-step mutual-help organizations in their community.
At a high level of description the assumptions in this model are:
· Addiction is a multi-faceted illness influenced by medical, social, emotional, and oftentimes spiritual factors
· Abstinence is the fundamental principle though not the only facet of recovery as emotion, family, employment, and civic growth are also important
· Twelve step participation is evidence based and shown to sustain recovery over the long-term
· Twelve step programs can’t help if one doesn’t attend
· A skillful clinical provider can help the patient address the common practical and attitudinal obstacles to twelve step participation.
A managed clinical trial report in 2009 (“Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial”, Kimberly S Walitzer , Kurt H Dermen, Christopher Barrick, Addiction, March 2009) reported good success across a substantial number of patients. “Participants exposed to the 12-Step directive condition for facilitating AA involvement reported more AA meeting attendance, more evidence of active involvement in AA and a higher percentage of days abstinent relative to participants in the treatment-as-usual comparison group. Evidence also suggested that the effect of the directive strategy on abstinent days was mediated partially through AA involvement.” Denial is a hallmark of substance use disorder and twelve step facilitation is designed in part to overcome that denial. There is evidence that this advance preparation is a form of treatment in itself that increases chances for success.
Motivational Interviewing and Enhancement Therapies are designed to help individuals resolve ambivalence about their alcohol and/or drug use.
Motivational Interviewing (MI) is often delivered as a brief intervention based on client-centered principles and emphasizes strategic use of common counseling skills. Advice is typically only given on request and with patient permission. Motivational Enhancement Therapies (METs) are interventions based on the MI approach and practices using clinically relevant, patient reported assessment data that is summarized and subsequently fed back to the patient in order to enhance motivation for change.
The core foundations of Motivational Interviewing began in the 1980s. At the time, it was seen as contrasting the more “confrontational” approaches common in residential substance use disorder treatment. It is assumed that patients already have what they need to initiate and sustain changes in their substance use as opposed to other CBTs that assumes that the client lacks those skills. The primary goal is to help patients resolve any ambivalence they may have about change and catalyze or mobilize that intrinsic motivation. The underlying principles are:
· Different patients come to treatment with varying levels of readiness to change
· Direct persuasion techniques may actually inhibit change in some patients
· Denial or resistance is not unhelpful but is a valuable tool to begin readiness discussions
· The clinician and patient are partners. Granting and respecting patient agency can produce powerful motivation for change
In “Motivational interviewing for substance use reduction” (Schwenker R, Dietrich CE, Hirpa S, Nothacker M, Smedslund G, Frese T, Unverzagt S.Cochrane, Database Systems Review, 2011 updated 2023) the authors found that MI had similar results to other approaches to treatment. “Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention and medium follow-up. For long follow-up, the effect was not significant. There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up.” Stated in dry, academic parlance that might be mistakenly construed as critical, the authors are saying that compared to no intervention this approach works in a similar fashion and as well as other treatments.
Acceptance and Commitment Therapy (ACT) is based in a psychological posit that suggests that when attempting to change a behavior it is important to understand how individuals form relationships between their inner experience and this behavior in order to help alter those relationships. ACT employs many aspects of mindfulness. ACT holds that it is human nature to avoid negative inner experiences, that fighting or avoiding those inner feelings they can be allowed and noted, clarity of personal values will help detach the feeling from the behavior. The patient is encouraged to:
· Detach from inner experiences
· Allow thoughts and feelings to arise without trying to change their form or frequency
· Remain in the present
· Let go of concrete and inflexible thoughts
· Learn what is most important
· Commit to efforts to behavioral change.
There seem to be few studies about ACT, and it seems premature to draw conclusions. The two studies listed on the Recovery Research Institute web site involved not the person with substance use disorder but the family member. No suggestion about which behavioral health condition is more rational for ACT suggested.
Holistic Therapies tend to be non-traditional from the perspective of “western” allopathic and osteopathic medicine. Although gaining in popularity in traditional medicine, including treatment for SUD, there is little research to discuss effectiveness. Types of Holistic medicine include:
· Acupuncture Aromatherapy
· Art Therapy, Music, Dance, Drama Therapy
· Equine/Canine Therapy Hypnosis
· Massage Therapy Meditation and Mindfulness
· Reiki Reflexology
· Yoga Instruction Wilderness Therapy
Cognitive behavioral therapy (CBT) became a mainstay and in some respects replaced psychoanalysis in the middle of the 20th century. CBT holds that unproductive or maladaptive thinking and behavior is the root cause of the problem. Regarding the treatment of substance use disorder, clinicians combine CBT with other theories. Many of the non-medication treatments that have been developed for substance use disorder fall under this broad cognitive-behavioral umbrella.
One use of CBT is Relapse Prevention, a skills-based approach that requires patients and their clinicians to identify situations that place the person at greater risk for relapse – both internal experiences and external cues. The patient and clinician work to develop strategies, including cognitive and behavioral to address those specific high-risk situations. With more effective coping, the patient develops increased confidence to handle challenging situations without alcohol and other drugs. This is an approach that acknowledges that one cannot fully avoid “people, places and things” as recommended in some twelve step programs.
The Contingency Management (CM) approach is sometimes also referred to as “motivational consequences”. It is comprised of a broad group of behavioral interventions that provide or withhold rewards and sometimes deploy negative consequences quickly in response to at least one measurable behavior. In Contingency Management interventions patients receive a reward for meeting a treatment goal.
CM is based on operant conditioning that theorizes behaviors are shaped by their consequences; they will increase over time if followed by a pleasant experience (reward) or decrease if followed by an unpleasant experience (punishment). Addiction is maintained and reinforced by a combination of the rewarding biochemical effects of the substance and environmental influences. Targeted behavioral change can be achieved through the systematic application of immediate, and certain, rewards and consequences, and individuals will be able to initiate and sustain abstinence as long as the rewards of abstinence are greater than the neurobiologically-mediated rewarding effects of substance use.
A study from 2013 (“Efficacy of Frequent Monitoring With Swift, Certain, and Modest Sanctions for Violations: Insights From South Dakota’s 24/7 Sobriety Project”, Beau Kilmer, Nancy Nicosia, Paul Heaton, Greg Midgette, American Journal of Public Health, January 2013) found strong evidence of success with CM. That study followed more than 17,000 residents of South Dakota who had participated in the 24/7 program for alcohol use reduction. They found, “At the county level, we documented a 12% reduction in repeat DUI arrests and a 9% reduction in domestic violence arrests following adoption of the program. In community supervision settings, frequent alcohol testing with swift, certain, and modest sanctions for violations can reduce problem drinking and improve public health outcomes.”
Our original premise in criticizing Secretary Kennedy was that continued progress in evidence based approaches to treating alcohol and other drug abuse and addiction is essential. Some reports by the NIH tell us that among all people with a substance use disorder less than 20% find treatment in any form and less than 10% achieve recovery if defined as one year of continuing abstinence. Given this record, regardless of the success of one or another approach to treatment, this expansion of thinking about treatment and application of new methods, followed by rigorous assessment is welcomed.
There is a trend evidenced in these methods. Specifically, many of these approaches hold the assumption that the client has the tools to address their SUD. This contrasts with the origins of the twelve step programs which formed the basis of many of the “Non-clinical” approaches operating today. At the start AA worked with only the lowest “bottom” alcoholics on the assumption that the radical changes being proposed would be appealing only to those facing the most severe consequences. As they had traveled far down the typical curve of negative consequence oftentimes these alcoholics had lost much of their capacities both internal and external to deal with their disease.
Today it is increasingly common to encounter those who have not progressed so far down that curve. Further, the stigma that kept people in more stable socio-economic circumstances from seeking treatment are receding if slowly. The result is that we now encounter individuals who still have the internal and external resources to manage this problem, and the treatments based in psychology and psychiatry are more available to them. Many of the “non-clinical” treatment programs most popular today will adjust. Others will continue to serve a population that has traversed far down that curve.
Further, as stigma slowly recedes more Americans know about the signs that a problem is or has developed. This, too, is occurring in other disease states. A recent Medstar report concludes that 64% of Americans believe they know the signs of stroke (though half of them did not get all he signs right). Similarly, the twelve question test for alcohol and drug addiction is much more widely known and more Americans are self-diagnosed or intervening for a loved one.
The approaches reported here are in varying degrees based in cognitive behavioral or talk therapy. Each is structured to get at the issues through awareness, understanding internal conditions, and motivating change. One can imagine their application on an outpatient or inpatient basis and in individual and group settings. To the extent that they open up opportunities for an increasing number of people with SUD these are very positive developments.
The continued use of twelve step participation in conjunction with any of these therapies seems prudent as recommended in several of the studies cited here. First, as we saw in the “Non-clinical Pathways”, and as cited in certain of these therapies, participation in community provides social reinforcement, awareness and the benefits of helping others all of which seem to contribute to immediate, short term and long term success.
Further, and finally, substance use disorder is a chronic disease much like diabetes, heart disease and obesity. There is no one-time cure as there are in other disease states but rather one makes changes, often in lifestyle that require sustaining which in turn requires maintenance. Today that maintenance seems best addressed best or at least most tested in twelve step communities.
Gene Gilchrist
May 2025
