On The Face Of It

        For the past nine months, I have been employed as a drug and alcohol therapist at a methadone clinic in Wilmington, Delaware.  I began last June, assigned a typical (about 60 individuals) caseload in the CORE methadone program.  My clients adequately represented a cross-section of the drug and/or alcohol dependent population and, as such, also a cross-section of the general population.  After three months at the clinic, my supervisors determined that I was appropriate to begin work on a fledgling program aimed at those clients who maintained an active addiction well into their methadone treatment; the individuals placed into this specialized program, “Recovery Counts,” are at risk for discharge from the clinic.  Thus, for the past six months, I have worked, within a groundbreaking format, with those individuals that are especially resistant to more traditional drug and alcohol treatment techniques. 

            When I was promoted to the Recovery Counts program, I was also asked to aid in the creation of a foundational curriculum.  Assuming most of the individuals within Recovery Counts harbor decades-old addictions and have been through repeated stints at outpatient and inpatient treatment facilities throughout the Mid-Atlantic, it quickly became apparent that traditional treatment was ineffective with this population.  Over the course of the program’s earliest inception, I scoured literature of drug and alcohol theory, treatment, and practice, attempting to find legitimate alternatives to the dominant mode of treatment.  My efforts yielded very little results.  There did not seem to exist a working model that challenged accepted methods entrenched in drug and alcohol theory for over fifty years. 

            Alcoholics Anonymous and the 12-step model of recovery originally grew out of the principles of a small, turn-of-the-century Evangelical society called the Oxford Group.  Throughout the 1940’s and 1950’s, a confluence of political and social forces acted on the original doctrines of the Oxford Group and it slowly evolved into a working model of alcohol dependence and subsequent “recovery” based largely on the Jungian idea of conversion, stated as a “spiritual awakening.”  The 12-step model later came to dominate the treatment of many seemingly disparate addictions: gambling, overeating, pedophilia.  It remains the most widely utilized form of treatment in the drug and alcohol field, gaining the working commendation of a reported 95% of current professional facilities in the United States. 

            The 12-step system is rooted in the disease model of addiction; the model maintains that certain individuals have no control over their addictions, that the ingestion of the alcohol or drug reacts negatively with the body and causes an “allergic reaction,” ultimately affecting the user’s self-control and judgment.  Historically, the synthesis of the disease model most likely arose as a philosophical concession between the leaders of the Temperance movement and the United States government following the repeal of Prohibition.  AA and its followers were rewarded for their effective social and political mobilization and lobbying in 1956 when the American Medical Association formally recognized alcohol addiction as a medical ailment.  Practically, over the past fifty years, the disease model has directly influenced the reach of the social worker within the drug and alcohol field. 

            The disease model relieves the alcohol and/or drug abuser of responsibility.  It eases the impact of addiction on the user’s family and friends.  By simplifying and medicalizing a very complex and organic social problem, the disease model tells the addict and those around him that he is merely the victim of circumstances beyond his control.  The disease model maintains that there is only one solution to the “disease”:  follow the 12-steps and submit to a Higher Power.  Paradoxically, this diagnosis and subsequent treatment effectively erode the individual’s confidence, encouraging, instead, submission to a worldview of unmanageability.  In spite of the progress that the client may make in a therapeutic setting, it is constantly undermined by the disease model; the drug abuser has been repeatedly told that he has a chronic disease (often likened to diabetes) that he will never be free of, and can only hope to maintain in “remission” for the remainder of his life.  Success is not expected of either the social worker in the substance abuse field or of his or her client.  The overwhelming acceptance of the disease model has, over the past fifty years, created a climate of lowered expectations and passive empathy.           

            It is important to note that the 12-step system and its accompanying disease model are successful for some.  There are some clients who embrace AA and NA’s principles and culture.  These individuals take great solace in a spiritual submission and succeed in achieving lasting abstinence and sobriety.  However, there are many individuals who would benefit from alternative forms of therapy.  These latter alcohol and drug abusers do not succeed at the 12-steps because they are turned off by its overtly religious sentiments, or feel uncomfortable having to share in the accustomed AA/NA group setting, or for any number of other reasons.  AA and NA doctrine accounts for these failures.  These individuals, AA insists, are not properly working the steps.  As a social worker, it seems imperative to offer alternate options to the client and, most importantly, to reassess and refocus efforts within this particular social problem.  Perhaps if so many clients are not succeeding within the established model of therapy, responsibility for that failure ought to be shared by client and social worker alike.  If the 12-step system insists that drug and alcohol abuse is a medical ailment, then there ought to exist a plethora of treatment options.  Certainly, if one is diagnosed with cancer, and chemotherapy is not successful, the doctor would not charge the patient with the responsibility for the failed treatment.  And that doctor would not continue to treat the ailment in the same way until it worked.  Rather, numerous other treatments would be attempted until the doctor and patient arrive at a suitable solution. 

            In individual and group therapy, the clients’ collective desire for alternatives is clear and unmistakable.  They have, most likely for decades, been ready for concrete options.  However, such options do not presently exist (the very few that do are not locally accessible).  The 12-step system and its foundational disease model have become inalienably entrenched in the social workers’ ethos in this particular field.  The ideas and concepts expounded in this essay must be discussed in hushed tones and quieted voices around the methadone clinic offices.  Such dissent is viewed as dangerous to the clients’ morale and confusing to their insight.  Despite the clear need for change within the substance abuse field and the clients’ quiet pleading for this change, there also exists clear and unwavering professional allegiance to the well established methods of treatment.  The 12-step system and disease models have become comfortable, stable concepts of assumed rationality which social workers may confidently and universally recommend.  Thus, the client who is mired in self-destructive patterns of alcohol and drug abuse fights a twofold enemy—the personal addiction and an antiquated and inflexible professional model of treatment.  Confronted with this overwhelming combination, many clients (such as those on my high-risk caseload at the methadone clinic) succumb to the substance abuse field’s underlying doctrine of hopelessness.  They continue to abuse alcohol and drugs, fulfilling the defeating prophecy of the disease model. 

            Substance abuse is a problem affecting every aspect of modern American society, transcending race, age, sex, and class.  It is an ever-present crisis, a war waged in homes and on the streets between.  Progress—individual and societal—has proved a Sisyphean task over the past fifty years.  The methods formerly employed are failing those who suffer both directly and indirectly; the failure can no longer be explained away, responsibility repeatedly being placed on the individual.  If there is to be positive evolution in the substance abuse field, it falls to the social workers, those engaged in direct service, to boldly spearhead alternative treatments.  Politics, economics, and social traditions aside, the paramount concern should be the individual struggling with substance dependence.  Conformity to established professional customs and beliefs is actively impairing many clients’ most earnest efforts at abstinence.  Every day that the minority of professionals in this field monitor the volume of their objections around the office is another day of addiction and disease for their clients.  The time has come for raised voices.