The Abstinence Myth in Treatment
Does a simple measurement for a complex problem work?
Posted Dec 24, 2017
I took a family call last week. The mother had a problem: her son had been in and out of treatment for heroin and benzodiazepines for the past two years, but nothing seemed to work. Each one tried to force the 12 Steps on him, but every time they failed, which is why the family came to us. Even though they wanted to try something new, they were weary from the journey and somewhat mistrustful. “What’s your success rate?” she asked, and she really wanted a simple number.
I get these questions all the time from clients and their family members. I completely understand the desire for a single figure that expresses the odds of success. Unfortunately, the real problem of substance use is not that simple, which means the solution most likely isn’t either.
The myth of sustained abstinence
A lot of addiction treatment centers advertise their success in simple numbers. One center here in Southern California claims that “70 percent of clients remain abstinent a year after treatment.” A national chain measures its success with a statistic called “percentage of days abstinent,” claiming that former clients were sober 92 percent of the time six months after treatment. Others go as far as saying that they “cure” addiction. What they never tell you is how they got to that number. The problem is that, typically, these statistics are obtained with dubious methods, like phone calls to past clients. Asking a former client the question “Are you sober?” can result in what researchers called a social desirability bias, whereby those who respond feel obliged to give the treatment center (where they spent a lot of time and money) the answer they know they’re looking for: “Yes.” The social desirability bias is especially strong when the questions can invoke feelings of shame, and I think we’d all agree that questions related to substance use fall into that category. Numerous studies [1, 2] have shown that when you compare self-reported substance use to biological tests (like breathalyzers or drug tests), you find that people substantially underreport their use. One recent study found that, while 97 percent of participants actually consumed alcohol (as measured by an ankle monitor), only 20 percent to 40 percent reported doing so . Obviously, we’re missing something big here, and most other treatment centers would rather not admit it.
A simple number for a complex problem
Even if abstinence is accurately measured, using this figure alone fails to recognize that addiction is a problem that goes much deeper than whether or not someone is sober — it is environmental, social, and psychological in addition to biological. Reducing it to a single success-rate statistic that only looks at substance intake does not even touch any of these deeper issues and is THE REASON why people keep relapsing. When we promote this sort of black-or-white thinking, we create the same mentality in our clients. If they only measure their success by abstinence, then any deviation becomes an indication of failure, and they get right back on the roller coaster (the abstinence violation effect; ). Real success comes when people see and feel improvements in their lives that they could not achieve when misusing substances. What the treatment community desperately needs is a true paradigm shift away from these simple numbers and the all-or-nothing mentality they create.
The IGNTD Recovery Approach
At IGNTD, we recognize that addiction is a systemic problem requiring a holistic solution. We offer personalized, customizable treatment plans to cater to the individual needs of each client. When we assess clients, we use well-validated research tools, like the Beck Depression Inventory (BDI) and the Addiction Severity Index (ASI), to measure baseline levels and subsequent changes in depression, anxiety, dependency, impulsivity, and more. By measuring outcomes in consistent intervals, we make sure that we are aware of our clients’ overall lives and not only their substance use.
Thanks to our data collection, we now know some very impressive things about our clients and their progress in treatment. Here are some of the outcomes we’ve been able to identify:
- 83 percent reduction in drinking (measured objectively with a Soberlink breathalyzer)
- 42 percent improvement in health functioning (RAND Medical Outcomes Survey)
- 191 percent improvement in personal view of substance use (Treatment Effectiveness Assessment)
- 20 percent improvement in general positive feelings (Positive and Negative Affect Scale)
- 31 percent reduction in alcohol use disorder symptoms (Short Michigan Alcohol Screening Test)
- 38 percent reduction in depression symptoms (Beck Depression Inventory)
Using these metrics, we at IGNTD are moving away from the black-or-white thinking of abstinence versus non-abstinence. We aim to improve our clients’ overall quality of life, and we never evaluate them solely on their substance use. By allowing our clients to choose their own path and accommodating them with individualized programs, we ensure the best route towards true success. And our clients thank us with an average 97 percent rating for their overall experience with us. This, along with their well-being, are the best gifts we could ask for.
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Wish, E.D., J.A. Hoffman, and S. Nemes, The validity of self-reports of drug use at treatment admission and at follow-up: Comparisons with urinalysis and hair assays. NIDA Research Monograph, 1997. 167: p. 200-226.
Magura, S. and S.-Y. Kang, Validity of self-reported drug use in high risk populations: a meta-analytical review. Substance Use & Misuse, 1996. 31(9): p. 1131-1153.
Alessi, S.M., Rash, Carla J., Barnett, Nancy P., Petry, Nancy M.,, Most patients in outpatient clinics continue drinking during treatment, in Research Society on Alcoholism. 2016: New Orleans, LA.
Curry, S., G.A. Marlatt, and J.R. Gordon, Abstinence violation effect: validation of an attributional construct with smoking cessation. Journal of Consulting and Clinical Psychology, 1987. 55(2): p. 145.