Nora Volkow MD is the Director of The National Institute of Drug Abuse and as such, she is the highest authority of substance use disorders in our land. She widely says that addiction is a chronic relapsing brain disease and that alcohol and drugs “hijack” our brains. While this view is debated hotly by many, Dr. Volkow and the majority of physicians as least in the United States subscribe to the belief that addiction is a disease of the brain and that the cure for people who have crossed the line into addiction is to become abstinent. Dr. Volkow reminds us that, “choices do not happen without a brain – it’s the mechanism of choice…and the quality of a person’s choice depends on the health of that mechanism.” She further says that, “an addicted person’s brain has a disrupted choice mechanism…and that these disruptions can persist even after decades of sobriety.”
Obviously the safest course of action for anyone who seeks to determine whether their drinking or drug use is addictive, disorderly, or causing problems in their life, is for that person to become abstinent. However, individuals just don’t work that way. We as people, value individual freedom, self determinism and personal choice. It is too easy for psychologists, psychiatrists, licensed professional counselors and drug and alcohol rehabs to recommend abstinence. If a client or patient is ready to follow this recommendation then the therapist or treatment center looks great an individual is said to be “cured.” So recommending abstinence is the safest bet, it covers professionals from a legal and malpractice standpoint, it offers hope to family and loved ones and makes sense from a clinical perspective as well. It’s just that the reality of expecting an individual entering drug and alcohol treatment to achieve abstinence initially and maintain abstinence is unfortunately misguided.
Most people do relapse. These numbers will be alarming. Meta Analyses, which are studies of studies and are the most powerful, reliable and valid measures of studies of human behavior. They reveal statistics and odds about the success of addiction treatment that can seem discouraging at first. The likelihood that anyone in treatment in a broad variety of treatment modalities during the course of the first year will remain clean and sober (i.e., abstinent) is between 10% and 30%. That is pretty bleak seeming if you are deathly worried that your loved-one’s drinking and driving, about to lose their job or suffering medical problems. However, when considered over a lifetime, the likelihood that someone will eventually no longer have a substance use disorder is as much as 70%. That is very encouraging. The reality is that people do relapse a lot and rather than expect abstinence we should work with relapse. In fact, “Relapse Prevention,” is the whole science of working with people in recovery to identify the underlying factors of relapse. Teaching people to identify what triggers their relapse by recognizing cues, signals, moods, thoughts and feelings which proceed relapse has been found to be an effective strategy in preventing relapse.
There are many clinical reasons to pursue abstinence from the onset in addition to obvious ones mentioned above. Many individuals considering changing their patterns of drug or alcohol use have not been sober for any protracted period of time. It may be that they have forgotten what it is like to be sober and they may be surprised, once they can give it an adequate try, how positive an experience it actually is. Most harm reduction approaches suggest abstinence as a first course with which to begin. So, this conversation should happen in the first session regardless. Therapists are encouraged to suggest a period of two weeks or one month even before beginning a course of controlled use, moderation management or SMART recovery. It is very important to be adequately and thoroughly evaluated by a trained substance use disorder expert because many people do not know that stopping certain substances suddenly including alcohol and benzodiazepines can cause dangerous medical complications, seizure and death.
It takes time for abstinence to work. Abstinence may seem like a litmus test for recovery outcome but it is not a cure. To get an “A” in recovery you have to not only be abstinent but you have to be recovering, to be sober. Many people use these words differently. I’ve heard people say, “They are clean but not sober” and “They are sober but not clean” and they mean the same thing. It is not enough to just be abstinent. The phenomenon of a “dry drunk” refers to someone being “dry” or “abstinent” but they still exhibit all the characteristics of an alcoholic, whatever we attribute those behaviors, thoughts and feelings to be. Getting abstinent as we say in the scientific community, is probably “necessary but not sufficient” for recovery. Once someone is abstinent they can tolerate the hard work of learning about themselves, learning how to communicate more effectively, how to take care of oneself, achieve greater intimacy and happiness in their lives. This is a process that usually requires individual and group therapy and a supportive community.
Abstinence is most likely the first step in true deep recovery. It is the first step in the 12-step approach. Once one admits that one is “powerless over addiction and that life has become unmanageable,” the only alternative is to stop using drugs or alcohol. It is only the first step however. Addiction recovery needs to be more than just stopping something, taking something away, avoiding something or just saying, “no.” Addiction recovery is more about what you add into your life. George Vaillant, the well known Harvard research psychiatrist, has demonstrated that recovery needs to have the support of four factors and this applies to those choosing to be abstinent or not. The four factors of recovery are 1) structure and supervision 2) social support 3) spirituality and 4) a non drug alternative to drug use or a ritualized dependency on something else…things that give meaning and purpose to one’s life. This then is the work of therapy and recovery. People have to replace their addictive behaviors with the rich four factors. They are like similar to what Freud emphasized when he discussed the only things that mattered in life which were work, love and play.