It’s a truism woven tightly into conventional wisdom, from bumper stickers to motion pictures: The only way out of addiction is through total avoidance of the subject of the addiction. One drink, one snort, and you’ll spiral back into helplessness.
Of course conventional wisdom isn’t always wise, and there is another school of thought in addiction recovery. Professional psychologists and psychiatrists, especially those trained in PTSD therapies, call it exposure therapy. The argument is that success can be achieved slowly and with purpose, even as people inevitably fail at times along the way. Progress may best be achieved not by abstinence, but by being exposed to the very drug which is feared to have caused so much havoc.
Abstinence-based religious peer support groups like Alcoholics Anonymous and Narcotic Anonymous inform their participants that they must be entirely abstinent from all substances. Twelve-step adherents are encouraged to count the number of days abstinent, and when they fail at their goal of not drinking or using, as they often do, they must identify as a newcomer, and restart their count at Day 1.
This belies common sense. And in addition to facing the failure itself, it certainly increases the stigma and shame of using and admitting to it. Members of these faith-based groups would surely shudder at the idea of immersing their participants in their drug of choice. Despite their best efforts to restart the clock, time continues at one second per second (sorry twelve-steppers: no going back). As Herman Melville once put it, “He who has never failed somewhere, that man cannot be great.”
We’ve learned a thing or two since 1939
Science has taught us a lot about habits since AA published their dogmatic Big Blue Book in 1939.
Every experience—even those we fail at—inevitably informs us about our inner and outer selves. Abstinence and absolute avoidance are archaic concepts—Dr. Albert Ellis would even say irrational—in that they distort reality, are not logical, and prevent one from achieving one’s goals.
Absolutes such as these cause harm and should be condemned to the ash heap of history. There are myriad ways to achieve mastery of maladaptive habits such as addictions, whether heroin/opioids, alcohol, cigarettes, coffee, or others. There are also myriad ways of stopping them, probably more ways than there are humans on the planet.
As with other aspects of life, our faith-based brethren would have us believe there is only one way: admitting your spiritual malady to a higher power and avoiding alcohol or other drugs at all costs for the rest of your life.
Exposure therapy often involves “in vivo exposure”—directly facing that which is feared or causing stress—and can be especially helpful when practiced with someone healing from trauma. Participants are often asked to put themselves in threatening situations to achieve mastery of their fear. Other modes of exposure therapy include imagination assistance and virtual reality, such as flight simulators.
The question with any given fear or addiction is which form is best at achieving the desired goals. Does alcohol use disorder get better statistically when people avoid it completely, or when they teach themselves not to fear it?
A recent article from the Clinical Psychology Review sheds light on the current understanding:
Poor adherence to evidence-based practice clearly has substantial implications for the care and treatment that clients receive, and hence for their subsequent clinical outcomes…. Therefore, it is important to understand whether training can help clinicians to implement evidence-based practice. [emphasis mine]
Despite well-documented evidence for the benefit of exposure therapy in the treatment of generalized anxiety disorder, these Danish researchers found that many professionals are not using it because they either fear it or do not understand it. We can and must do a better job in addiction medicine at teaching and employing evidence-based practices.
A Danish randomized controlled study of cue exposure therapy (CET) as aftercare for alcohol use disorder points to some clues. They analyzed ‘sensible drinking,’ which in Denmark is under 14 drinks per week for women and under 21 drinks per week for men. The findings were complex and interesting: comparing CET to traditional cognitive behavioral therapy, exposure therapy may be superior for patients with pronounced alcohol use disorder and inpatients at treatment facilities. In other cases, the findings were complicated and inconclusive.
Despite the dearth of data regarding exposure therapy, and whether facing one’s fear is better than the complex act of avoiding or denying behavior, we know that there are multiple pathways for multiple individuals, and this often involves revisiting their drug of choice either adaptively or maladaptively. Either is possible. Which path will work best, and when, for any given individual is a question addiction medicine has been asking for a very long time.
As many of these studies in psychology and habits say, “more research is needed.” More people can be helped if the doctors begin to take away the fear and penitence of using, and meet people in the real world where adults (and some teens) use drugs—sometimes even with very positive consequences.