“Letting a hundred flowers blossom and a hundred schools of thought contend is the policy for promoting progress in the arts and the sciences…” —Chairman Mao Zedong
It is not every day that one is inspired to turn to the work of Chairman Mao when discussing the status of addiction treatment. On the other hand, these are not ordinary times.
When addiction treatment in the United States was in its infancy, one philosophy predominated. Treatment centers were staffed almost exclusively by those in recovery, whose experience of personal redemption through immersion in self-help programs inspired them to promote the philosophy of Twelve Steps. With little empirical research to guide the field, a consensus emerged that there was one way, and only one way, to recover: by practicing the principles of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) “in all our affairs.” This, in turn, led to a zealousness that soon morphed into dogmatism; a “one size fits all” rigid insistence that any treatment approach not firmly grounded in Twelve Step principles and attendance at Twelve Step meetings was doomed to fail; that clients who could not find it in themselves to embrace the philosophies of AA and NA were in need of aggressive confrontation to break through the wall of denial; and that those who used medications responsibly to treat comorbid psychiatric conditions were violating the fundamental tenet of abstinence. Interestingly, this was not the case in other countries, who from the start embraced a more eclectic approach to treatment. Nor was it consistent with Twelve Step literature, which urged recovering members to inspire others through their experience, strength and hope, and which understood that aggressive persuasion would only undermine internal motivation. In the words of the AA Big Book, “When a man is presented with this volume, it is best that no one tell him he must abide by its suggestions. The man must decide for himself” (p. 144).
Many things have changed. The workforce has become increasingly professionalized. A wealth of outcome studies have convincingly demonstrated the efficacy of other approaches, such as Motivational Interviewing and Cognitive-Behavioral therapies, and have documented the fact that many who recover do so without any treatment or Twelve Step involvement whatsoever. There is no question that a commitment to science and critical inquiry has broadened the field and brought it into the mainstream in a way that can only be healthy for the field and for our clients.
However, we are now at a point where a new orthodoxy is threatening to prevail. Professional organizations are amassing lists and registries of evidence-based treatments. States are beginning to require that reimbursement be contingent on providing treatments from a list of “officially approved” approaches. Treatments not appearing on such lists are commonly assumed to be ineffective. Although it makes imminent sense to try to use the scientific method to separate the clinical wheat from the chaff, there is a very real threat that in doing so we will squelch the spirit of innovation and creativity that will be needed to keep the field vibrant. The articles in this volume are a refreshing antidote to this trend. They all describe novel treatment approaches, or apply concepts from other areas of the social sciences to clinical work in the addiction field.
Penn and colleagues apply a qualitative methodology to address an important question: How do counselors and clients differ in describing their experience of Twelve Step and SMART Recovery meetings? Of particular interest is their finding that, for clients, the most positively experienced aspects of both meetings were the interpersonal interactions, rather than specific ideology or content. This is consistent with a growing recognition that, in addition to identifying effective therapies, we need to more clearly delineate the qualities of effective therapists. Consistent with the work of John Norcross, evidence-based relationships contribute as much, and likely more, to outcome than evidence-based treatment modalities.
We were fortunate to receive a series of three submissions from a related group of collaborators. In the first of these, Aslan used a mixed-methods design and semistructured interviews to evaluate the Phoenix Futures Recovery Through Nature Programme. This program is an innovative, nature-based approach based on therapeutic community principles, which draws as well from Wilson's biophilia hypothesis, Clinebell's work in eco-therapy, and Hall's theoretical model. Their results provide an interesting window into the experience of clients who participate in this program.
In the second of these submissions, Aslan, Parkman, and Skagerlind use quantitative and qualitative methodologies to evaluate the MFAS program, a novel intervention using professionals and people in recovery to provide education and enhance motivation around attendance at Twelve Step or SMART Recovery groups. Their work provides helpful guidance for clinicians around clients' experiences in the program and documents their success in facilitating participants' involvement in mutual aid groups. Perhaps most notable is their finding that participants appreciated learning about multiple approaches and being empowered to select the types of mutual aid they felt fit best for them.
The third in this series is Parkman and Lloyd's paper, which applies Anderson's concept of “imagined communities” to recovery communities. They explore the role of shared language in creating a sense of community, and challenge us to reconceptualize the nature of recovery communities in an electronic age and to consider the ways in which electronic media can cultivate a sense of community among people in recovery who may never interact face-to-face.
Finally, like Penn and colleagues, Sotskova and colleagues apply concepts derived from research on the role of nonspecific factors in treatment, in this case group cohesion and group alliance, to clients participating in LifeRing, a substance abuse peer support group. Their findings take us one step closer to understanding the complex interaction between alliance, group cohesion, group participation, and satisfaction with treatment, and to conceptualizing peer support groups using well-established concepts from the group psychotherapy outcome literature.
Together, these papers provide fertile ground for cultivating a rich efflorescence of treatment philosophies and approaches. Just as species diversity is one index of the health of a biological community, so, too, can diversity in approaches be a marker of the health of the treatment community. Let us strive to ensure that our treatment philosophies and approaches are as diverse and complex as the clients we serve.