New Recovery

Invitation to Guest Authors

2008-02-24T20:45:00.000-08:00

Guest authors are invited to contribute to this blog. I have to take another break until the end of June. I'm working on a book with a June 30 deadline.

Confrontation Therapy, R.I.P.

2008-02-19T22:31:00.001-08:00

Two of my favorite scholars have combined to write a powerhouse of an article that everyone interested in addiction treatment will want to read. William R. Miller, co-author of the Handbook of Alcoholism Treatment Approaches (reviewed here), and William L. White, author of the monumental history Slaying the Dragon (reviewed here), have written what hopefully will be an obituary for an era, entitled "Confrontation in Addiction Treatment." It's in Counselor Magazine. Here are a few snippets from this substantial, strongly researched and comprehensive treatment:

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

....

Early claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).

...

There never has been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Quite to the contrary, research on virtually any measure reflects wide diversity of personal characteristics among people with addictions, who are about as diverse as the general population, or as snowflakes. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes (Donovan, Hague & O’Leary, 1975).

...

Reviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.

If you've ever been exposed to confrontation therapy, or have a confrontational counselor now, by all means read this article, sure to be reprinted in textbooks and to become a classic.

If there's one defect in it, it's in glossing over the confrontational therapy element in AA itself. Dr. Harry Tiebout, whose psychiatric theorizing framed the confrontational approach, was hugely influential on Bill Wilson, and he was not alone. Dr. Silkworth echoed the theme, with his advice to Wilson to "give them the medical business, and give it to them hard." The "medical business" meant to convince the alcoholic that he was suffering from an incurable fatal illness. This revelation was designed to attack and to "shatter" the alcoholic's defenses, to "deflate" his ego, and render him hopelessly dependent on his "physician." The very first clause of step one, the foundation of the whole edifice, "powerless over alcohol," expresses a confrontational strategy, as thousands of counselors have found out in practice. To be fair, this is not the only element in AA; there are other strands that tend to counterbalance it. But the article is certainly wrong in claiming, as it does, that there is no attack therapy strand in AA at all. -- This cavil aside, the article is a masterful piece of work, by two giants in the field. Highly recommended.

Abstinence leads to rapid brain repair

2008-02-06T01:01:00.000-08:00

Abstinence leads to rapid repair of gross brain damage seen in alcohol dependent persons, according to a review of neuroimaging studies by a group of Japanese researchers.

In uncomplicated alcoholic patients, a high incidence of cortical shrinkage and ventricular dilatation were reported using brain CT scans. In older alcoholics, prefrontal gray matter deficits were especially marked when compared with younger alcoholics. Reversibility of brain shrinkage is a common neuroimaging finding in patients with alcohol dependence.

Regrowth of shrunken brain areas was particularly vigorous during the first month of abstinence, the scans showed. Besides the gray matter, areas "with significantly greater recovery in abstainers were the temporal lobes, thalamus, brainstem, cerebellum, corpus callosum, anterior cingulate, insula, and subcortical white matter." Follow-up studies showed that the regrowth was not simply due to rehydration.

The study appeared in the Dec. 2007 issue of the Japanese Journal of Alcohol Studies and Drug Dependence. The abstract is here.

Brazil study: Does AA really work?

2008-02-06T00:36:00.000-08:00

"Do Alcoholics Anonymous groups really work? Factors of adherence in a Brazilian sample of hospitalized alcohol dependents." -- That's the title of a study in the current issue of the American Journal of Addiction, published by a American Academy of Psychiatrists in Alcoholism and Addiction. A team of researchers headed by M.B. Terra followed 300 alcoholics committed to three hospitals in Puerto Allegre, Brazil. Results (from the abstract):

AA adherence was below 20%. The main factors reported by patients as reasons for non-adherence to AA were relapse, lack of identification with the method, lack of need, and lack of credibility. The factors reported by patients as reasons for adherence were identification with the method and a way to avoid relapse. Although AA is considered an effective intervention for alcoholism, its adherence rate was excessively low. The identification of these nonadherence factors could help health professionals in referring certain alcoholic patients to therapeutic interventions other than AA.

The result of this study is unsurprising; essentially the same finding was made in a meta-analysis almost two years ago reported in the Cochran Report (Source) What's noteworthy here is that patients were asked their reasons. It would be useful if the various threads in the responses (objections to the 12-step approach on the one hand, denial on the other) were explored in more depth and an attempt made to untangle them.

2007 Darwin Award Nominee: Alcohol Division

2008-01-24T15:55:00.000-08:00

Michael was an alcoholic. And not an ordinary alcoholic, but an alcoholic who liked to take his liquor... well, rectally. His wife said he was "addicted to enemas" and often used alcohol in this manner. The result was the same: inebriation.

The machine shop owner couldn't imbibe alcohol by mouth due to a painful throat ailment, so he elected to receive his favourite beverage via enema. And tonight, Michael was in for one hell of a party. Two 1.5 litre bottles of sherry, more than 100 fluid ounces, right up the old address!

When the rest of us have had enough, we either stop drinking or pass out. When Michael had had enough (and subsequently passed out) the alcohol remaining in his rectal cavity continued to be absorbed. The next morning, Michael was dead.

The 58-year-old did a pretty good job of embalming himself. According to toxicology reports, his blood alcohol level was 0.47%.

In order to qualify for a Darwin Award, a person must remove himself from the gene pool via an "astounding misapplication of judgment." Three litres of sherry up the butt can only be described as astounding. Unsurprisingly, his neighbors said they were surprised to learn of the incident. Source. Thanks, John C. (Goathouse) for the item.

Humility R Us [NOT]

2008-01-13T21:50:00.000-08:00

It's been six years since AA Trustee Dr. George Vaillant's article in the AA Grapevine, saying that "It doesn't hurt at the level of the GSO for AA to have humility and understand that 60 per cent do it without AA." Source. He was talking about the research finding that 60 per cent of alcoholics who achieve at least five years of abstinence do it without using AA.

It's been six years, and Vaillant's plea for humility has either not been heard or already forgotten. In this months' issue of Addiction Professional, columnist Carlton Erickson reports that "fourteen experts" recently met at a "consensus conference" in Rancho Mirage CA to define "recovery," and came up with a definition that includes an implied endorsement for "peer support groups such as AA and practices consistent with the 12 Steps and 12 Traditions."

In other words, judging by Erickson's column, if you're part of the majority that are staying sober without AA you're not considered in recovery. But if you're a chain-smoking Big-Book thumper whose entire social, moral, and intellectual life is wrapped up in AA meetings, then you're a model of recovery. The mind boggles.

The panel's full report, published in the Journal of Substance Abuse Treatment, is considerably more balanced than Erickson's column makes it seem. The report says that "the founders of AA recognized that there were many paths to the same position ... and did not suggest that their specific methods were the only means to attain the overall goal." (Thanks Jason Schwartz for forwarding the full article.) The panel considered but expressly rejected the definition of recovery as "abstinence attained through adherence to 12-step principles."

That's progress. But the plug for AA and the 12 steps is highlighted in the report, and Erickson's column picked up on that highlight, as most hurried readers will.

This endorsement is completely gratuitous. It comes in the absence of any evidence cited in the report showing either (a) superior efficacy of 12-step over other paths in reaching long-term sobriety, or (b) a positive association between long-term participation in 12-step groups and measures of "personal health and citizenship."

The report admits that no validated instrument for measuring "personal health and citizenship" exists. Then what scientific ground is there for making the claim?

The implied beneficial effect of AA participation on "personal health" is indefensible given the notorious prevalence of nicotine addiction among AA members. The report takes note of the nicotine problem, including "significant rates of emphysema, cancer, and other terminal health conditions associated with these products among those otherwise in recovery" (read: in AA). But come to the bottom line, the panel tucked tail between legs and "considered it best to remain silent on tobacco use within the sobriety component of the recovery definition."

The next line is lovely: "It is admitted that there is no clinical justification for this position."

The claim that long-term AA participation enhances "citizenship" is equally dubious. The cited ground for it is the AA homilies for doing service, "giving back." But this "service," to the limited extent people actually do it, is in the nature of recruiting for the AA organization. AA has no outward-directed community service component on the order of the Masons, Shriners, Rotarians, and many other groups. So where does "citizenship" come in?

Trying to come up with a definition of recovery is a laudable project. The panel notes that recovery science (as distinct from addiction science) is a poorly developed field, and that the lack of a validated definition of 'recovery' is a significant obstacle. But when you enter the gates of science, the motto is "lasciare ogni sospetto" -- here drop all hesitation, abandon all fear. So long as recovery scientists keep genuflecting to the sacred cow in the room, little progress and considerable dung is to be expected.

Alcohol Killed 'The Prophet'

2008-01-07T07:43:00.000-08:00

The excellent New Yorker continues its literary war on the alcohol-as-muse delusion. In the Jan. 7 issue is a thumbnail bio of Kahlil Gibran, author of the huge bestseller, The Prophet. After the success of this book, Gibran took to drinking heavily. Eight years after The Prophet, having produced nothing further of note, he died of cirrhosis of the liver, at age 48.

Bankrupt Tobacco Firm Floats Whiskey-Flavored Cigs

2007-12-28T10:50:00.000-08:00

Whiskey-flavored cigarettes and cigarette papers dosed with vanilla to disguise the stink of the smoke are among the "new technology" being marketed now in Quebec by JTI MacDonald, a Japan-based cigarette company that is in bankruptcy proceedings.

Public health advocates are up in arms. Read more here. Thanks, Michael W., for the item.

If liquor doesn't get you, nicotine will

2007-12-21T20:15:00.000-08:00

Last week's New Yorker had a bio of Malcolm Lowry, a lauded writer whose alcoholism claimed him at age 47; see my blog note, "Alcoholocaust," below. This week's mag covers iconic short story writer Raymond Carver (What We Talk About When We Talk About Love), also an alcoholic, but one who got sober in 1977, and stayed that way. But he kept smoking. He once said that he was only "a cigarette with a body attached to it." Lung cancer claimed him at age 50.

The mag's Lowry story took the author down a notch or two by suggesting that his wife was actually responsible for much of the greatness in Under the Volcano. The mag continues on its debunking tear by demonstrating beyond reasonable doubt that the savage blue pencil of Carver's editor Gordon Lish was responsible for creating the terse, minimalist style that made Carver famous.

Score: New Yorker 2, theory that alcohol helps the creative juices flow, 0.

Oh, and don't miss the cartoon on p. 68. A bar patron drinking coffee to a neighbor with a cocktail: "Been there, drunk that." I'd copy it here but I worry about overstretching the boundaries of the "fair use" doctrine.

Let them drink Grand Marnier!

2007-12-21T19:43:00.000-08:00

A proposal out of Tacoma to "treat" chronic street alcoholics by banning the sale of cheap wine caught the fancy of S.F. Chronicle columnist C.W. Nevius last week. The scheme is simple: in a defined "alcohol impact zone," stores are banned from stocking Thunderbird, Boone's Farm, Royal Gate, Takaa, and similar cheap rotgut.

If the homeless alkies want to buy Cabernet Sauvignon or Grey Goose, that's ok.

Public health authorities in Tacoma laud the idea, citing reduced emergency room admissions and other medical costs. That's not surprising. The same thing happened nationwide during Prohibition.

The logic by which Nevius calls this simple class-based Prohibition scheme "treatment" escapes me. It's just one more aspect of the ubiquitous economic bias that Prof. Merrill Singer describes so vividly in his recent book, "Drugging the Poor," reviewed here.

Back from Iraq with a monkey on their back

2007-12-16T23:26:00.001-08:00

Jon Marshall's News Gems website writes:

"ABC News' investigative team, led by Brian Ross, worked with six graduate journalism students to discover whether troops returning home after serving in Iraq are facing the same battles with drug addiction as soldiers did when they came back from Vietnam. For their series, "Coming Home: Soldiers and Drugs," the students traveled across the country from Fort Carson in Colorado to Fort Bragg in North Carolina to examine the accuracy of the Army's assurances that drug abuse among ex-combatants isn't growing. Their findings:

Many of this country's bravest men and women who volunteered to defend America in a time of war have come home wounded -- physically and mentally -- and are turning to illicit drugs as they adjust to normal life, according to soldiers, health experts and advocates." Source.

The five programs are available online here.

Afghan farmers see through "drug war"

2007-12-16T23:04:00.000-08:00

Recent U.S. initiatives to eradicate poppy fields in selected areas of Afghanistan, on the Colombian model, have met with growing resistance by Afghan farmers, according to a briefing paper by the Afghanistan Research and Evaluation Unit (link):

"The view that the government is willing to deepen the poverty of some of its rural population for the sake of a ban on opium poppy cultivation further alienates the rural population. The belief of many farmers that those enforcing the ban and eradicating their crop are themselves actively involved in the opium trade makes matters worse; so does the perception of widespread bribery and the sense that eradication targets the vulnerable and ignores the crops of those in positions of power and influence."

Afghan farmers are seeing that the eradication efforts are aimed mainly at growers or dealers who are competitors to the growers and dealers connected with the Afghan government and its sponsors. A secondary aim of eradication may be to reduce the over-all supply in order to maintain prices. The Afghan farmers are seeing firsthand what the "war on drugs" is all about and they're not buying into it. The study's authors caution that Afghan farmers will continue to grow the poppy until they're presented with a reasonable alternative -- and none is in sight.

Girl, 8, asks cops for help with drunken mom

2007-12-16T22:21:00.000-08:00

"Help me. My mother is drunk, and she crashed her car," said an 8-year old Tampa FL girl to troopers last week who were checking on a car wreck.

With the girl inside, the mother had sideswiped two other vehicles before hitting a parked car head-on and coming to a stop. The girl got out of the wreck, unhurt, and approached the first officer on the scene.

"Ever time she drinks she gets like this," said the girl. The mother was booked for drunk driving, child abuse, and related charges. Source.

Sponsors rat on pigeon

2007-12-16T21:18:00.000-08:00

Two Alcoholics Anonymous sponsors took the witness stand in federal court in Des Moines IA recently to denounce their former sponsee, Thomas Vasquez, as "a pathological liar" lacking "the capacity to be honest." Source.

Vasquez probably deserved the slams. He was a paid government informer trying to build a case of extortion against incumbent Democratic state senator Matt McCoy. A Bushie federal prosecutor brought the transparently political case. The jury threw it out after less than two hours of deliberation, including lunch.

But ... should AA sponsors be testifying as character witnesses against their former sponsee? Isn't that against some rule?

War of the drugged

2007-12-16T20:57:00.000-08:00

From the Guardian (U.K.):

The army today admitted that cocaine was becoming the "drug of choice" for British service personnel.
Colonel John Donnelly, who has responsibility for army discipline, said a significant increase in drug taking by soldiers could be linked to stress induced by the demands of combat operations.
More on this topic.

Whine tasting

2007-12-16T20:51:00.000-08:00

It had to come to this.

The California Republican Party issued two press releases attacking the California Democratic Party for spending campaign money on a wine tasting fundraiser.

The Democrats shot back, pointing out that the Republicans spent four times as much on wine for their events, plus sending untallied bottles of a rare vintage to major donors. Source.

Dual diagnoses have same root?

2007-12-16T20:17:00.000-08:00

Substance abuse and mental illness very commonly go together. One hypothesis to explain the correlation is to see the patient using alcohol/drugs to medicate the mental disorder. Another view sees the mental disorders as the symptoms of excessive drug/alcohol ingestion. Now comes Dr. Andrew Chambers and his researchers at the U of Indiana Medical school with a study that suggests both theories are wrong. Based on experiments with adult rats, Chambers found that both substance abuse and mental disorders probably stem from a malfunction in the amygdala, a small region within the brain that plays a role in numerous processes, including the memory of emotionally charged events. Read details. Read blogger Jason Schwartz's piece on the same issue, here.

Don't wait till kids are in middle school

2007-12-16T17:42:00.000-08:00

A study of underage drinking finds a big jump in alcohol use in children between the fifth and sixth grades, and suggests that waiting to deal with an alcohol issue in the home until the child is in middle school is too late. Source.

The researchers urge parents to "talk to their kids about alcohol" when the kids are ten or eleven, or earlier. But talking alone isn't going to cut it, if the parents themselves are setting bad models of alcohol use in the home. The research really suggests that if one or both of the parents have an alcohol problem, the time to deal with it (at the latest) is when the kid is still in primary school.

Marijuana smoke nastier than cigs

2007-12-16T17:36:00.000-08:00

Dec. 14, 2007 -- New research from Canada shows that some toxins may be more abundant in marijuana cigarettes than tobacco cigarettes.

The researchers burned 30 marijuana cigarettes and 30 tobacco cigarettes on a machine in their lab, measuring levels of chemicals in the smoke.

Ammonia levels were up to 20 times higher in marijuana smoke than in tobacco smoke. Levels of hydrogen cyanide and nitrogen-related chemicals were three to five times higher in marijuana smoke than in tobacco smoke. Read more.

99 per cent wouldn't use drugs if legal

2007-12-16T17:26:00.001-08:00

A recent poll of 1000 U.S. adults asked if they would use "hard" drugs such as cocaine or heroin if they were sold legally. More than 99 per cent said they would not. Source.

The numbers undercut the argument of "war on drugs" supporters that drug prohibition is a necessary dam against widespread drug use.

Quite the contrary, says David Borden, CEO of StopTheDrugWar.org. For example, rates of marijuana use in the Netherlands, where it's sold legally in "coffee shops," are only about half those in nearby France, where marijuana use is an arrestable offense.

Evolution at work

2007-12-16T17:02:00.000-08:00

A drunk man in Thailand stopped to urinate and poked his member through a crack in a fence.

On the other side of the fence, a vigilant puppy spotted this invading one-eyed albino rat, and promptly sank its teeth into it.

Doctors at the hospital said the member "should still be useful" to the man in the future. Source.

A good question

2007-12-16T16:56:00.000-08:00

A new policy in New Jersey allows cops to ask drinking drivers who served them their last drink. Source.

Some bar owners are upset because existing law already makes barkeepers liable for serving patients who are drunk.

Cops answer that the question helps them spot bars that ignore the law.

Surprising finding about youth drinking (NOT)

2007-12-16T16:43:00.000-08:00

A study of 11,000 persons in London found that teens who drank to excess (4 drinks or more per session, once a week or more often) were twice as likely to snag a criminal conviction by age 30. They were also much more likely to become alcoholics, to use hard drugs, and to become homeless. Source.

The study is being used as fodder for an Australian provincial government campaign to crack down on youth drinking. A worthy cause, no doubt, but did the study control for factors such as family income, education, and environment?

College profs modeling alcoholism for students?

2007-12-16T16:25:00.000-08:00

College students' drinking excesses continue to make news. A prof at R.Y.S. (wherever that may be) points out in his or her blog that the students may just be copying their profs.

"Can we acknowledge that there is a huge amount of alcoholism in academia? Not the cute Dudley Moore kind, but the kind that makes us less sharp and ends our lives early? I'd imagine every one of us knows a colleague who needs a mid-morning 'refresher' or who always smells slightly of drink. I remember seeing my supervisor trying to be inconspicuous checking all the (empty) wine bottles at a reception, hoping there was a glass left in one of them, and finally making a glass by combining all the remnants red and white wine that were left. I remember drinking with him at a local bar until well past midnight (having started at four). And is there any function in academia that doesn't involve alcohol?"

Read the whole thing. Good point. A college administration trying to cope with its students' alcohol excesses needs also to look in the mirror. It'll be hard to get a handle on student conduct if the faculty's drinking is out of control.

CIA up to its old tricks?

2007-12-16T15:58:00.000-08:00

A tantalizing hint that the CIA is up to its old tricks (flying drugs from conflict zones) surfaced in the crash landing of a Gulfstream II business jet in Mexico Sept. 24.

The Florida-based craft carried somewhere between three and six tons of powder cocaine, and either no heroin or up to one ton of heroin, depending on which estimates one believes.

The flight originated in Colombia and was destined for Florida with a stopover in Cancun.

Blogger FrostFireZoo.com reports that the serial number of the craft matches those of a plane used by the CIA on at least three occasions in the rendition of terrorism suspects from Guantanamo to other countries to be tortured.

A Mexican journal accused Mexican and U.S. political authorities of hypocrisy for waging a so-called "war on drugs" on the one hand, and being heavily invested in the lucrative drug trade, on the other.

Foxfire.com observes that the amount of drugs said to be on the plane diminished with every official Mexican press release on the incident, and speculates that the subtracted amounts disappeared back into the market.

The photos of the crash scene, above, originated with Mexican press sources. For a video with commentary on EVTV, click.