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Demystifying rehabs

What talking therapies are used in UK rehabs? Deirdre Boyd conducted the UK's first study on this.

There is an evidence base to the therapy in rehab - and it will be familiar to many traditional therapists

Sadly, too many myths about “12-step treatment” for addictive disorders are held by too many people, even drug- and alcohol-treatment professionals and policy makers and ‘traditional’ generic psychotherapists.  Indeed, the Nice guideline on Psychosocial Interventions for drug treatment (which it refuses to update with research from the past decade) confuses residential treatment with detoxification, while The Mind: A User’s Guide written in collaboration with the Royal College of Psychiatrists stated that “the” reason to refer people to treatment is to detox.

But detox is a purely physical phase, a mere first step (if people are lucky) to psychosocial support. Detox, at its worst, is like the ancient romans purging to empty themselves – to make space to drink more. Rehab and recovery are about stopping the use of substances which relentlessly cause harm.

Some professionals do relate “12-step based treatment” to therapeutic interventions, but do not link it to their own familiar skills. One damaging effect is that people desperate for help are thus not referred to the most effective, appropriate treatment for them.

However, if we can clearly relate the therapies applied in “12-step treatment” to those practised by mainstream therapists and psychologists, not only could there be a growing base of understanding referrers to send clients to appropriate treatment but also – if those professionals could attend brief workshops relating their skills to the 12 steps – the workforce capacity to treat addictive disorders could be multiplied by thousands of people. We have started disseminating a similar approach to help life/ executive coaches understand how they can safely guide vulnerable people into recovery.

First UK survey. To put together a picture of what therapies were used by 12-step treatment centres, a few years ago I sent a questionnaire to all UK addiction treatment centres. Over 30 responded; we whittled this down to 27 for the table at the end of this blog, omitting private practitioners who responded. Given the small number of UK rehabs, this is a significantly large-enough sample to be representative.

Cognitive behavioural therapy. I often hear people speak of CBT and 12-step-related treatment as though they are mutually exclusive. So it is worth noting that 100% of respondents blend them seamlessly, so clients benefit from the best of both. Rehabs are eclectic in their use of therapies, as they confirmed in this study.

Motivational interviewing. MI is more often seen as complementary to 12-step-related therapy than CBT – indeed, it is recognised as enhancing many approaches. But it is perhaps surprising that a 100% consensus of respondents blend this into their approach.

Project Match – and mixing. The world’s largest research into the outcomes of treatment for alcohol dependency, Project Match, compared CBT, MET and what they considered a ‘pure’ form of 12-step facilitation (TSF) therapy. The results were very comparable, with TSF slightly ahead – but it is also worth noting that the reality in the UK is that treatment centres/rehabs use all three, working towards a common goal of restoring alcohol- and drug-free lives.

“Clinicians: as long as you are giving one of these three treatments,
you need not worry!”

stated one of the researchers, Richard Longabaugh, professor of psychiatry and human behaviour at the Brown University School of Medicine.

“All three therapies – CBT, MET and TSF – induce similar
process activities in the clients,”

added lead researcher Professor Carlo DiClemente, chair of the psychology department at the University of Maryland.

In the UK, the mix of therapies can be due to individual therapists. “While we use a 12-step model, individual therapists differ in their interaction with clients in the sense that some are CBT trained, person centred or integrative,” said Steve Benson Cole of Cygnet Health.

A similar approach was taken by Michael Ishmael who used to work at Odaat: “We have different therapeutic interventions and practitioners in our service. They bring a vast range of skill, practices and therapeutic approaches, ranging from humanistic to the more psychoanalytical”.

Clinical team leader John Trolan of the Nelson Trust structures a mix into clients’ care plans. “Rather than having an eclectic mix, we integrate appropriate therapies into treatment plans so it would not be uncommon for clients to attend, say, a psychodrama group while seeing a cognitive-analytical practitioner. It depends on their needs,” he explained.

Family systems therapy. Reflecting the importance of family members for a client’s recovery, 85% of treatment centres offer family systems therapy, sometimes parenting groups.

Reasons for linking to 12 Steps. The request for other reasons as to why organisations regarded themselves as “12 step” was inadvertently ambiguous, and many instead explained why they availed of this principle.

“We promote affiliation because evidence indicates that it gives our clients the best prospects of maintaining abstinent recovery and building a healthier lifestyle. This is not from a position of dogma, but with the objective of helping clients to make an informed choice about how they will conduct themselves after treatment” said Kirby Gregory, director of client services at Action on Addiction.

“One of the important areas which this highlights is the question ‘what are the personal obstacles to you engaging with this valuable support network?’ – and this becomes a central focus of the treatment programme. The client has the opportunity to identify and change aspects of their attitudes, beliefs and behaviours to allow them to access support which is vital to ongoing recovery. An interpersonal group therapy model is key to our approach.”

Western Counselling chief executive Amanda Lea stressed that “We very much use the structure, nonjudgmental challenge, honesty and integrity inherent in the steps”.

Mike Delaney responded that “Project Match has shown the 12-step model to be among the most successful treatments to date. It is flexible and can be used with a host of complex clients, even when they have issues with religion, God, or groups”.

ANA Treatment Centres founder Libby Reid listed reasons for linking to 12-step support as:

  • provides ongoing support after treatment anywhere in the world
  • provides a pattern and design for living
  • can be adjusted to fit a client’s individual belief/value system.

Ishmael highlighted “acceptance and support, even love, within a peer-led environment”.

Susan Giles of Abbey Gisburne concluded on a pragmatic note. “We recognise that not all our patients will choose the 12-step way. All we can do is give them the choices to help their recovery,” she said.

Client involvement in plans. The questionnaire did not ask about client involvement with their careplans, but some of the treatment centres volunteered this as a key principle: “We review the programme at each grade of achievement”.

Steps to collaboration. Language is often a barrier to joint working and referring people who desperately need help to the most effective treatment organisation. Perhaps we should refer to treatment centres and others who work with addicted clients as “12-step-related”. This emphasises commonalities of the core psychotherapeutic and behaviour-change processes, rather than being misinterpreted as a regime unfamiliar to mainstream, generic professionals, some of whom have in the past seen mutual-aid fellowships as a threat to their counselling work. Combining professionals and mutual aid often yields the greatest successes.