Minnesota is the land of 10,000 lakes, and some say, the land of 10,000 addiction treatment centers. The actual number of addiction treatment centers is really more like 400. Regardless, Minnesota put addiction treatment on the map by developing the very first formal treatment approach for addiction. It’s called The Minnesota Model and has been replicated across the world and has helped millions of people. The 12-step philosophy of AA and NA is an integral component of the Minnesota Model.
“The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
– F. Scott Fitzgerald
12-step or CBT…really?
I am a psychologist working primarily in the area of addiction. I often hear 12-step programs pitted against evidence based treatments such as Cognitive Behavioral Therapy (CBT). It’s as if as a clinician, I have to somehow chose a side, and then stick to it. It’s 12-step or CBT.
At this point in my career, I’ve grown weary of the word or. In CBT the tendency to think in either/or terms is called “black and white” or “dichotomous” thinking. This type of thinking can lead to a lot of mental and emotional suffering. Modern American society is full of examples of headline-driven questions. They make us feel forced to choose a side: do guns kill or do people kill? Are you a Republican or Democrat? We pideon-holed in an either/or dilemma.
Now, most rational and reasonable people would likely concede that when trying to understand a phenomenon, it’s best to take an approach that can account for multiple variables and potential influences. However, we as humans seem to have a natural tendency or desire to align ourselves with a particular “camp”.
The Field of Psychology
In the field of psychology, these camps are based on different theories of the mind and human behavior. Theories are useful and necessary and serve as a framework for trying to understand these things. However, holding onto a particular theory too tightly can sometimes cause us to miss the forest for the trees.
The field of psychology has also at times fallen victim to dichotomous thinking. Especially when trying to understand the origins and treatment of human suffering. This has led to questions such as: Is it nature or nurture? Is early attachment or temperament more important? Are mental health problems best described in categories of symptoms or better understood on a continuum? Is it the technique or the skill level of the clinician that produces change? The list goes on and on. Intuitively we know the answer is probably somewhere in the middle, but we still feel pressure to cling to one particular camp.
Human Behavior is Complex
During graduate school I felt pressure, mostly from myself, to come up with my own unique theory of human behavior. And I thought I had it figured it out by the end of my training. Now over a decade into my career, I’m realizing that I know much less now than I did back then. My theory is much less clear. And that’s a good thing.
I now teach at the school I graduated from. I teach a course called Counseling and Personality Theories. Each semester I intentionally start off by discussing some of the existing research. This research indicates the theoretical principles you pick make less difference than other variables such as the therapeutic relationship and client factors. This forces students to sit with the frustration of not having a simple, clear answer, and to instead appreciate the complexity of human behavior.
The Many Questions of Addiction Treatment
Take addiction for example and in particular the behaviors that arise from addictions, which are among the most complex and confusing of all human phenomenon. The addiction field has to grapple with some of its own often befuddling questions, with research pointing to both sides being true:
Is addiction a chronic, progressive disease that requires intervention or do most people get better on their own, without treatment?
Are substance use disorders caused by genetic factors (biomedical model) or are they the result of trying to cope with difficulties in life that may arise more from environmental
factors such as poverty and racism (self-medication model)?
Is complete abstinence necessary for full recovery or can people live a quality life while still using substances?
Should family members detach and protect themselves as not to enable? Or can they actually influence the behavior of their addicted loved one?
Do you need a personal history of struggling with addiction to be able to understand and treat it, or do you need a high degree of training and professional licensure?
We have some big questions facing the addiction field and how we are going to evolve our understanding, prevention, and treatment of addiction. Perhaps the least helpful response to this profound conundrum would be to fall into black and white thinking and look for simple answers and then divide into camps. In many ways, there is still a lot we don’t understand about addiction. Most experts can’t even agree on a shared definition of addiction. And there are many, many different pathways to addiction.
Dialectical Behavior Therapy (DBT)
One of the greatest advances in behavior therapy over the last several decades has been Dialectical Behavior Therapy (DBT). Created by Marsha Linehan, and now disseminated and used all over the world, DBT has been shown to be effective for a variety of difficult to treat conditions. The philosophy of the approach is based largely on the idea of a “dialectic”, which assumes everything has its contradictions or opposing forces. In essence, it involves the art of holding two opposing ideas in mind; specifically with DBT, balancing change with acceptance. Approaches like DBT have taught us the importance of language, and the power of the word and.
The ultimate dialectic in providing care for people with addiction may be that you need to approach the addiction as a primary disorder and the underlying factors that make it feel necessary to the individual. When we can’t prevent it, people suffering from addiction deserve the best possible treatment we have available. And we will only arrive at the most effective treatments by bringing everyone together from all the various camps.
A New Frontier
I call upon the addiction treatment community and everyone who has been impacted by addiction. We must embrace a Minnesota Model 2.0, that brings together everything that MN has to offer, without losing what made this model great in the first place. The focus needs to be on integration, not exclusion. And not or.
It may be time to take a step back from what we think we know about addiction and come together to better understand it. Then we can build the integrated treatments that will actually heal the whole person who has the addiction. It isn’t going to be just one approach, it’s going to be the product of people coming together and finding the best blend for the most people. And then even that won’t work for all people. And we will need to sit with the frustration, the ambiguity, the confusion, and keep forging ahead.
We will need to have some difficult conversations and we will need to bring people together who have very different ideas about addiction and how to treat it. Going through this process will be a good thing for the addiction field, but more importantly, for the individuals and families at risk for, or currently struggling with, addiction. We owe it to future generations to put in this difficult, messy work, so we can come out with something even better.
Dr. Jason Reed is an Addiction Psychologist, Adjunct Professor and Clinical Director at Kodiak Recovery. Kodiak Recovery provides high-quality care, consulting, training and advocacy and is committed to improving the quality of care and outcomes for all individuals struggling with addiction and co-occurring disorders in the state of Minnesota.