The New DSM-5, and what it can mean for you…
Alcohol Abuse & Alcohol Dependency
Why Treatment Differentiation is Long Overdue
Since its inception, virtually all treatment approaches for the varying degrees of alcohol misuse have assumed that all clients are alcohol dependent “alcoholics” despite over fifty years of research to the contrary. Now the DSM 5 will be defining alcohol abuse along a spectrum and there is at least an implied mandate that treatment also needs to address the various stages across the spectrum.
It isn’t going to happen.
Remember that over 90% of treatment facilities, inpatient or outpatient, rely on AA and the 12 Steps as their only “solution” and that this approach recognizes only two client categories – you are either an “admittedly powerless alcoholic” or you are “in denial.” No exceptions. No other “tools.” No spectrum.
As the old maxim notes, “if the only tool you have is a hammer, then every problem becomes a nail.” Consequently, if the only tool you have is AA, then everyone with an alcohol problem must be an “alcoholic.” Even when they aren’t. Especially when they aren’t.
The problem is that the vast majority, up to 85% in some estimates, of people seeking help with their alcohol problems are abusing alcohol, not dependent on it. So if 85 out of every 100 potential clients are being mislabeled, and it is a label, not a diagnosis, then why would anyone be surprised that treatment fails?
What is interesting is to look at the rare few programs that start from the opposite assumption – that all clients are abusing alcohol, not dependent – until proven otherwise.
Those programs and practitioners start by doing a real assessment, not the automatic “alcoholic” or “in denial” designation. That means taking a careful case history, conducting a cost/benefit analysis, seeking collaborating observations (i.e., including, not excluding spouses or partners), and, in the most comprehensive paradigms, using Dr. Jane Loevinger’s model and measure of ego development, the Washington University Sentence Completion Test, to assess the applicability of AA to clients regardless of their degree of alcohol involvement.
Yes, real assessment takes time, effort, skill, and attention to client’s strengths, interests, abilities, and motivations. It means discovering the unique mosaic of reasons each client has for drinking to excess. It also means treating individuals, not groups, and also using real tools, tools custom tailored to each client.
Real tools that have been proven to be effective: Brief Therapeutic Interventions, CBT, Motivational Interviewing, Naltrexone, Assertiveness Training, Diet and Exercise, Mindfulness, and a host of other skills that can be taught and incorporated into a person’s day-to-day life. Tools that replace abusing alcohol with a life that’s better without it than with.
That also means vastly improved success rates and outcomes that are not labels, and an end to the revolving door treatment model that is currently the industry norm. That’s why change isn’t going to occur. The current model is a business model, not a client success model, and as such it is predicated on the endless recycling of vulnerable clients.
That’s a problem compounded and supported by the “disease” model of addiction. While this may have some basis at the actual end stage of the spectrum, it prevents the “problem” drinker, for example, from recognizing their misuse as a choice and deciding to make a different choice. That is, after all, how most of us change a problem behavior, whether drinking, drugging, smoking, or overeating. We recognize that it’s time to make a different choice.
It is also why the search for the “right” medications is fruitless. For alcoholism, or abuse, they already exist in Antabuse and Naltrexone. But people who choose to keep drinking simply choose to skip taking the meds. In that regard, drinking is no different than bi-polar disorder. People forget the negative consequences and/or miss the positive, and eschew their medications.
Until they choose a different day-to-day life and different ways, either positive or benign, to deal with the anxiety, loneliness, boredom, grief, pain, oppression, and myriad other factors that constitute the real reasons they engage in self-medication.
Until we are prepared to see the misuse of alcohol, other drugs, food and so on as symptoms, not diseases, and address the underlying factors with an individualized mosaic of solutions, we are condemning the vast majority of clients, and would-be clients, to the treatment mills’ revolving doors and labels that actually justify and exacerbate abuse and addiction. Under the current system, why would any competent adult voluntarily agree to “treatment?”
And that’s where the problem really lies. As with actual diseases and medical conditions, we know that early intervention results in better outcomes, more options, and less expense. But “rehab” is such a disreputable business that no one is going to voluntarily sign up for what’s offered. Would you accept a demeaning and debilitating life long label and voluntary segregation from “normal” into a cult with a long term “success” rate of less than 5%? This for a condition you don’t even have?
Think for a moment about the process a patient with a real medical condition goes through:
- They are assessed using objective tests and instruments;
- They are encouraged to seek second and even third opinions;
- They are offered a variety of treatment options including no treatment;
- They are assumed to be capable of making decisions in their own best self-interest until proven otherwise;
- Their wishes are respected.
But in the rehab industry?
- They are assessed as alcoholic or in denial because either they showed up or someone said so – no criteria are necessary or wanted. In fact, any suggestion that there may not be much of a problem is rejected as “in denial;”
- Everything possible is done to prevent looking for options and, frankly, few options exist since almost everyone is selling the same “hammer;”
- No treatment options are offered since real options would require the use of experienced and trained – read expensive – staff and would lower relapse rates;
- Perspective clients are assumed to be incapable of making decisions for themselves – after all, if they could, they wouldn’t be seeking treatment, which has its own irony;
- Clients’ wishes are never respected because, again, they are not capable of making appropriate choices – and there is only one appropriate choice and we all know what that one is.
It’s no wonder that rehab has its well deserved con game reputation, and no wonder people don’t seek help until there is no other choice.
But changing that means at least giving people more than one choice. In means letting people know that early intervention is possible; that AA is not “the only way” or even remotely the best way. It means educating people to the symptomatic nature of alcohol abuse and the ways in which it can be reversed as well as eliminated.
To learn how all of the may apply to you specifically, just give us a call and let’s do an informal, free, and open consultation?
We think you’re entitled to at least that much. Don’t you?