‘“It doesn’t work for everyone” – a take on 12-step approaches’ by DJMac

iStock_000011501444XSmall-300x199Excellent blog from the DJMac website. Good discussion as well.

‘What follows is a guest blog by a GP who gives a personal view on professional perspectives of mutual aid:

I was astonished the first time I was taken to an NA meeting. I mean, really gobsmacked – you could have knocked me off my seat. The room was full of recovering heroin addicts; something I’d never seen in my 20 years (at that time) in practice.

I was both excited – at the possibilities – and ashamed – at the fact that I didn’t know such places existed. It curls my toes to think of it now, but I had not referred my patients to them. That was a while back.

When I began to talk mutual aid with colleagues in practice and with our local addiction psychiatrist, I observed a peculiar thing in many people – a resistance to the concept of self-help at best and downright hostility at worst. I was pretty solidly bamboozled.

Nothing I was doing was working hugely well. I mean, methadone was kind of making things a bit better, but I wondered who was benefiting the most; the patient or society.

I was being trained in the evidence for reducing the risk of blood borne virus transmission and reducing crime but that helped society as much as it helped the individual. Don’t get me wrong; I prescribe methadone and Suboxone, I’m convinced that harms are reduced, but I’m yet to be convinced that lifelong prescribing is what everyone wants or needs.

What did the individual want? A normal life. Not to be tied to chemists or prescriptions or be in this relationship with a prescriber where there might be unpleasant consequences if they screwed up. And, lets face it, is the nature of addiction in so many people not to screw up endlessly until they pare away all the things that are important to them?

Who wants to be at the mercy of the prescriber as to the ‘consequences’? That’s a top down relationship. As I say, don’t misunderstand, I’m absolutely convinced of the value of replacement therapy, but folk need to know all the options and for that to happen, I too need to know all the options.

I’m not saying this top down thing was what it was like everywhere or all the time, but you heard some horror stories of patients being punished. I remember a colleague making a patient wait a while (a long while) for a prescription because they had missed an appointment, or another forcing the patient to pick the prescription up at a chemist (pharmacy) miles away from where the patient lived as a ‘punishment’ for being late.

Then there’s the spectre of forced reductions. Does that still happen I wonder?

“It doesn’t work for everyone”
Once I took a look at the evidence about mutual aid, I wasn’t shy – not a bit of it. I asked colleagues what beefed them about AA and NA. These were the sorts of answers I got:

– It doesn’t work for everyone (the commonest response)
– It’s dangerous to come off methadone
– There’s not a bit of evidence behind it – that’s what the specialists said
– It’s religious mumbo-jumbo
– Drug dealing happens at NA meetings
– Patients don’t like it
– It’s non professional – “these people” don’t know what they are doing
– Or another version of that – these places are not regulated
– Everybody goes to the pub after an AA meeting
– Nobody stays clean
– Talking about addiction doesn’t make addiction go away

And so on. It was amazing how many folk had so many rationalisations that effectively acted as barriers to their patients getting to meet other recovering people.

Of course, not everyone was like that. Many colleagues were open-minded. There was this addiction consultant who firmly believed AA could do more than he ever could and got so many people there. His name was mentioned by patients a lot of times because of that.

Underlying reasons
What did I think was behind these opinions and perspectives? A lot of things.

Ignorance was one, but lack of understanding of what the evidence says doesn’t explain the emotional response, the degree of resistance that some colleagues have – there’s something else going on there. I think it’s better now but the response, “it doesn’t work for everyone” was like a refrain ten years ago.

I began to have to bite my lip when I heard it because it was such a common reply and I started to find it amusing. Paracetamol [Tylenol to American visitors] doesn’t work for everyone who has a headache, but we try it and see if it works, because it works for quite a lot of people. I don’t get the retort “it doesn’t work for everyone” when I talk about paracetamol. Paracetamol doesn’t get folk arguing or getting emotional.

I think part of it is feeling threatened by a process – recovery – that takes place out of the consulting room or clinic. It is non-professional, but instead of being a bad thing, this is actually perfectly healthy and the way it should be.

Most of us go into the caring professions to help people, but some of us are threatened at our core when our patients need less of our help than they once did. Those of us who are like this are not very likely to have insight to see it. I think that’s part of what’s going on in some people when mutual aid comes up. It disempowers the professional. [I think the author is absolutely right here – DC]

Then there are philosophical or ideological objections. People will argue endlessly about whether the 12-step programme is spiritual or religious. For some, one is as bad as the other! They prefer to turn a blind eye to the atheist and agnostic members of AA because they undermine the firmly held objections.

The bottom line is they don’t like it so they don’t think their clients should go. I’m sorry to say that there’s plenty of that around. [I agree -DC]

SMART Recovery might make a difference. Then there are plenty of recovery community things, other than mutual aid, around. It doesn’t have to be like that though. It shouldn’t be like that.

Getting better
In any case, the evidence is strong and getting stronger that mutual aid, recovery community resources and connecting to other people in recovery is right at the heart of long term, sustained, healthy recovery. Professional objections to mutual aid might be heard less often these days, but my gut feeling is that the problem has not gone away.

At the moment, groups like Narcotics Anonymous and Cocaine Anonymous are exploding in our area. SMART is going from strength to strength. Recovery is visible on the street and in communities. That’s great!

I still wonder though how much effort professionals put in to getting clients along to mutual aid. I do think it’s better than it was, but I think it needs to get a whole lot better still.

As I say, mutual aid has an evidence base. It’s true that “It doesn’t work for everyone”, but it works for many and unless someone knows something I don’t, we don’t know who it will work for and who it won’t, so let’s give everyone a shot at it and get as many of our patients or clients connected as we can.’