PARADIGM CHANGE

Paula DeSanto leading group session

Paradigm change is underway. Many factors are contributing to the development of new approaches for substance use treatment. These include leaders in the field teaching about person-centered care, scientific advances, evidence based practices, research on substance use patterns, new definitions of both addiction and recovery, and consumer desire for alternative approaches.

While most treatment programs continue to use the 12 step approach, this section describes many factors leading to paradigm change, and outlines the primary reasons for the development of a new model – The Minnesota Alternative.

 

Scientific Advances

 

We can now study the functional brain. Advances in neuroscience have great implications for the delivery of addiction treatments that allow for brain "opportunities" instead of brain "illness".

The brain is very powerful because it is so sensitive to experience. Where we place our attention defines us at a neurological level and we have far more power to alter our brain, our behavior, and our personality than previously thought possible. There are many ways to train our brains. Some techniques include: focused concentration, mindfulness, repetition, mental rehearsal, positive experiences/emotions, and new and novel experiences. These methods can help us to change our thoughts, our emotions and our behaviors.

Practitioners often refer to addiction as "hijacking" the brain, implying that if one struggles with addiction their brain in out of their control. The problem with this theory is that it fails to take into consideration that many people recover from addictive behaviors on their own. It also fails to recognize that the command center of the brain, the frontal lobe, when engaged, can quiet the "hijacked" midbrain. In fact, mindfulness practices have been shown to quiet the different regions of the brain that make up the "craving network".

Clients have displayed strong enthusiasm and interest in learning about how their brains work. They feel empowered knowing they can learn to engage their frontal lobe, thus improving their ability to self-regulate. A client commented, "I have been in so many treatment programs and the only tools I leave with are to go to AA meetings and get a sponsor. Now I have a bunch of tools. I have learned how to use my brain to think greater than how I feel, and I have learned many skills to help me think differently."

 

Policy Recommendations and Evidenced Based Practices

 

System change can be very difficult, and is often met with resistance. However, national organizations are promoting change by defining policy and practice recommendations based on research informed and evidence based practices. They are also increasing public access to research information. Providers are increasingly held accountable to produce measureable outcomes.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA)/ National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have come forth with policy recommendations that emphasize the need for person-centered interventions. To highlight a few:

  • No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.
  • Research shows that combining treatment medications, where available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches must be tailored to address each patient's drug abuse patterns and drug-related medical, psychiatric, and social problems.
  • Addiction can affect so many aspects of a person's life, and treatment must address the needs of the whole person to be successful. This is why the best programs incorporate a variety of rehabilitative services into their comprehensive treatment regimens.
  • NIDA recommends that treatment programs include:
    • Cognitive Behavioral Therapy
    • Motivational Incentives
    • Motivational Interviewing
    • Group Therapy
    • A menu of services that include medical, psychological, social, vocational, and legal support.

 

Research on Substance Use Patterns

 

Another factor contributing to paradigm change is research on patterns of drug and alcohol use. Addiction is often referenced as chronic and progressive. While this may be the case for some, it is not true for most. Research shows that the majority of people, who meet the criteria for substance dependence, do not continue to meet the criteria over time.

In 2001/2002, (NIAAA) conducted the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the largest study ever conducted. (Sample size of n = 43,093) and concluded:

  • Twenty years after the onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.
  • Many heavy drinkers do not have alcohol dependence. For example, even in people who have 5 or more drinks a day (the equivalent of a bottle of wine) the rate of developing dependence is less than 7 percent per year.

According to a publication from NIDA - Drugs, Brains, and Behavior: The Science of Addiction: Drug abuse starts early, peaks in teen years, and rarely occurs in older adults. Age is a limiting factor in the use of drugs and alcohol. One longitudinal study showed no initiation into alcohol or cigarette use after age 29, and very little first-time use of any other drugs after that age. In fact, most people stopped using illicit drugs by age 29. Daily users of alcohol and marijuana decreased their use by this age and only cigarette smokers continued to use and increase daily use with age.

 

Defining Recovery

 

According to SAMHSA's newly revised (2011) definition of recovery. "In recovery" used to mean someone who is abstinent after a struggle with substance use. The definition no longer includes the need for abstinence and emphasizes the unique paths each person takes toward recovery.

SAMHSA's definition in 2009: "Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life."

SAMHSA's definition is 2011: "Recovery from Mental Disorders and Substance Use Disorders: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential."

 

Consumer Desire for Alternatives

 

More than 90% of alcohol and drug treatment programs in the U.S. are based on the 12 steps of AA (SAMSHA, 2010) . Providers incorporate AA, yet often do not practice AA's inclusive principles.

A colleague shares his perspective:

Treatment providers can learn from the way AA accepts people who may be ambivalent about abstinence, rather than require people to commit to abstinence as a condition for treatment. AA accepts people into a meeting even if they arrive with alcohol on their breath, while treatment providers often send people away or may even discharge them. AA says "progress not perfection". Treatment providers say commit to abstinence even if you aren't ready for that and then be perfect or we discharge you – and by the way, we are an honest program so don't lie about using, but we'll kick you out if you are honest and tell me you use; or we'll try to catch you with random drug screens.

Almost thirty years of clinical experience and working in a variety of settings, have provided a rich opportunity to serve clients throughout the continuum of care. During this time, many clients have expressed how treatment has been ineffective and unsatisfying. Multiple clients have gone so far as to describe their experiences as torture.

During an interview with a woman she shared that she had been kicked out of a residential treatment program because she was "toxic" to the therapeutic setting. She went on to explain that she was asked to leave for questioning the principle of surrender, as she did not find this concept helpful. These negative experiences are disheartening; along with the message clients receive about being toxic or a failure.

Failure was a frequent occurrence, but perhaps it was the treatment that was failing the person, not the person failing the treatment.


  1. Dispenza J (2007) Evolve Your Brain: The Science of Changing Your Mind
  2. National Institute of Alcoholism and Alcohol Abuse (2006) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) #70.
  3. McGonigal, K (2011) How Mindfulness Makes the Brain Immune to Temptation. The Science of Willpower.
  4. National Institute of Drug Abuse (2009) Principles of Effective Treatment: A Research Based Guide (2nd edition).
  5. National Institute of Alcoholism and Alcohol Abuse (2006) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) #70.
  6. National Institute of Drug Abuse (2009) Drugs, Brains, and Behavior: The Science of Addiction.
  7. Chen, K., & Kandel, D. (1995). The natural history of drug use from adolescence to the mid-thirties in a general population sample.  American Journal of Public Health, 85, 41-47.
  8. SAMHSA Press Release (2011) SAMHSA announces a working definition of “recovery” from mental disorders and substance use disorders.
  9. SAMHSA Press Release (2010) Office of Applied Studies. The N-SSATS report. Clinical or therapeutic approaches used by substance abuse treatment facilities. Rockville, MD: US Dept. of Health and Human Services.