In addition to 12 step approaches, a number of other psychosocial approaches exist including, therapeutic communities, psychodynamic approaches, behavioral approaches, cognitive and cognitive-behavioral approaches, relapse prevention, community based approaches, family approaches, and group therapy approaches (Hartel & Glantz, 1999). Despite this diverse range of program approaches in the United States, on the whole, the treatment system rests on high-threshold access to treatment meaning that abstinence is required to enter and remain in treatment.
It operates under the assumption that most must “hit bottom” before change can occur. Responsibility for “failed treatment,” is placed on clients who are viewed as unmotivated to change. In regard to this “blaming,” White says the following: Alcoholics and other addicts have suffered, not only as a result of poorly developed and at times harmful treatment technology, but also through being blamed for their failure to respond to such technology.
For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; And when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness, and dependence.
Blaming protects the service provider and the service institution at the expense of the addicted client and his or her family. Defining failure at the personal level can also mask broader failures of social policy. (1998, p. 331) The focus on abstinence within traditional substance treatment poses significant barriers to treatment access, as most programs make abstinence mandatory in order for an individual to receive treatment and view individuals who are not immediately interested in complete abstinence as treatment-resistant or untreatable (Miller & Rollnick, 2002).
In addition, the rigid and confrontational approach of traditional drug and alcohol treatment approaches (often based on the Synanon model) appear to alienate prospective clients (Tatarsky, 2002). Traditional programs place the therapist or drug counselor in charge of treatment planning. This top down approach to treatment gives the client little voice in guiding the therapy and often fails to meet clients where they are in terms of their readiness to change substance use patterns.
It can also fail to address many of the complex biopsychosocial needs they have, which effect their drug and alcohol use (Prochaska, DiClemente, & Norcross, 1992). These would include the lack of available services for housing, education, and medical treatment; the impact of racism, poverty, and oppression on minority groups in our society; the lack of employment opportunities for many families; the multiple challenges of treating those who may be dually diagnosed; and the many nuanced psychological issues that may undermine motivation for treatment.
Finally, the focus on God and the theocentric emphasis of 12-step based treatment may be very difficult for some individuals who are agnostic or from backgrounds other than the Judeo-Christian tradition to accept (Marlatt and Donovan, 2005). Alcohol and other substances may be thought of as multi-purpose tools often used in the service of adapting and coping in a given environment (Alexander, 1997). For many, substances have important personal meaning or have come to serve seemingly life-sustaining functions and are believed to be vitally important as long as no better alternative solutions are identified or available.
Some of the potentially adaptive functions served by substances include the use of drugs for self-medication and self-soothing, to defend against painful affects, to cope with negative emotions, and as a source of pleasure and escape from a chaotic and capricious environment (Tatarsky, 2002). Whether an individual is conscious or not of motivations to use substances, any consideration of stopping is frequently met with intense anxiety, or is simply unthinkable.
Given the important functions that substances can play, it is often necessary for users entering treatment to unwrap the multiple meanings that substances have for them and to discover alternative ways of performing these functions. This takes place as they continue their use before most can even consider reducing use as possible (Tatarsky, 2003). In general, harm-reduction-based treatments for substance abuse accept the client where they are in terms of use, and focus on reducing the harm caused by that use, not on reducing their use per se (Denning et al. , 2004).
The focus is shifted away from substance use itself to the consequences of harmful substance using behavior. Treatment is based on the rights of individuals to make their own choices regarding their substance use and changes in use. The goal is to engage the user as a collaborator in planning their treatment and identifying treatment goals; this involves identifying and employing the client’s strengths and motivations in the service of positive change. In harm reduction, engaging clients in treatment, regardless of the treatment goal is preferable to no treatment at all (Marlatt & Witkiewitz, 2005).
From the perspective of consumers of substance abuse treatment, the development of less theistic, more tolerant, non-stigmatizing, widely available, and affordable alternatives to current treatment systems are needed. To address this, such an alternative treatment model based on incorporating harm reduction and mindfulness techniques into a treatment protocol to meet the needs of individuals who would benefit from reduced alcohol and drug consumption have been proposed (Tatarsky, 2003).