John N. Chappel

Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to clients needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.

Using AA and other 12-step programs more effectively

EVEN THE BEST intentioned health professionals may refer people with alcohol and other drug abuse problems to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) groups without providing them a minimal understanding or preparation. This article describes some characteristics of the groups to which persons are referred and some ways to enhance the positive outcomes of referrals to these groups. We do not use the term self-help, because it is not an accurate description of AA or other 1Zstep programs. Keep in mind that some alcoholics do not require formal health care; they may approach 12-step groups directly and initiate their recovery in that fashion. Knowledge and understanding of the 12-step groups in your locale may facilitate the entry and recovery of your clients/patients. These programs are a resource that helps health professionals deal with the estimated 15% to 20% of clients/patients in an office practice and 30% of general hospital clients/patients who meet criteria of addiction to alcohol and/or other drugs (Johnson, Phelps, & McCuen, 1990). It is especially important to understand the characteristics of 12-step programs because the prospective study by Vaillant (1983) attributed 7% of the variance of good clinical outcome to “stable adjustment, married, employed, never detoxified” but 28% of the variance to attendance at AA meetings (over 300 meetings). AA is more important over the long term than professional treatment. Most well-educated professionals know the general clinical characteristics of alcoholism, but fewer know

Working a program of recovery in alcoholics anonymous

WE q INDEBTED TO Khantzian and Mack, hereafter refer&l to as “the authors,” for providing useful stimulus examining how Alcoholics Anonymous (AA) works. All health care professionals working with alcoholics need to have both knowledge and skill in helping their clients/patients utilize the valuable treatment resource AA provides. The authors’ current article builds on the work begun by Bean (1975) and Mack (1981) in providing a scientific rationale not only for the program of AA but also for the spiritual stimulus that appears to contribute so much to recovery from addiction. With regard to understanding the spiritual aspects of AA, the authors have added little to their observation that “the idea of God, or a power greater than oneself, may be a step in the direction of taming and transforming infantile omnipotence and serving in early childhood to establish a capacity for objective love” (Khantzian & Mack, 1989). This valuable theory is supported by Coles’s (1990) research on the spiritual life of children. It is also supported by the clinical experience of grandiosity and omnipotence associated with deteriorating and lost object relationships that occur so often in active drug-addicted individuals. In their current article, the authors, in their conclusion, have added a definition of spiritual life “as the longing for or experience of meaning, purpose, or connection with an unknown reality behind the manifest one and a higher self both within and outside the person.” It would be very helpful if they gave examples showing how the clinician can use the spiritual aspects of AA to help the addicted patient speed up and deepen her or his recovery.

Training of Residents and Medical Students in the Diagnosis and Treatment of Dual Diagnosis Patients

Treatment of dual diagnosis patients requires simultaneous treatment of the addictive and the mental disorders. Available data suggest that this does not happen often. In a survey of several psychiatric services, the unit chiefs reported that dual diagnoses were underreported, no plans were present for combined treatment, families were infrequently involved, and few referrals were made for combined treatment. There is a need for competent, experienced clinician teachers who have had positive experience with the treatment of dual disorders. The training of addiction and mental health professionals must include cooperation, understanding, and respect for each other. Cross-training is needed in chemotherapy, psychotherapy, abstinence from alcohol and other addictive drugs, 12-Step programs, spiritual issues, and milieu therapy. Negative attitudes and ignorance must be overcome for this training to take place. Faculty Fellow training programs have provided a beginning in this direction, but have so far involved few professional schools. Some examples of training with regard to referrals, prescribing, and psychotherapy are given. The importance of supervised clinical experience in treating dual diagnosis patients is emphasized. The provision of this experience provides a challenge to specialists in addiction medicine and addiction psychiatry.

SUBSTANCE USE DISORDERS: Difficulties in Diagnoses

Patients attempt, consciously or unconsciously, to minimize or disguise their substance use, in part to preserve shreds of self-respect, avoid guilt and shame, and avoid the real or imagined criticism of others. It is ironic that substance users not only use the substance to gain access to pleasant events or escape or avoid unpleasant events, but also to deny, minimize, or disguise that very use for the same reasons.