Substance Abuse Treatment Today

By David Kolker, JD, LCSW

step by step written on blackboard with chaulk

Roughly 3-5 percent of individuals completing inpatient treatment remain sober for 12 months or more. Is a 95% failure rate acceptable in any other business? Why has the treatment industry been doing the same thing for 50 plus years and somehow expecting a different outcome, absent substantial change?

History supports treatment as an adjunct

The approach to substance abuse treatment for the past 50 years has been a crash course on the 12 steps. There is no doubt that the 12 steps provided a much needed solution to issues related to alcoholism; however, Bill Wilson’s stated intention was not to discount or deny the importance of treating the entire person as an adjunct to the 12 steps. Moreover, Alcoholics Anonymous was to be forever non-professional, with the stated primary purpose “ to stay sober and help other alcoholics to achieve sobriety.”

Bill Wilson, in a talk presented to the New York City Medical Society on Alcoholism, April 28, 1958, stated:

When our combined understanding and knowledge have been fully massed and applied, we of A.A. know that we shall find our friends of medicine in the very front rank – just where so many of you are already standing today. When such an array of benign and cooperative action is in full readiness, it can, and will, surely be a great tomorrow for that vast host of men who suffer from alcoholism and from all its dark and baleful consequences.

Thus, Bill Wilson clearly was in favor of:

1. Keeping AA non-professional;

2. Accepting outside help as part of the goal to treat the alcoholic; and

3. Understanding that the alcoholic, in many cases, needs help from professionals in conjunction with AA

The treatment approach for the past 50 years

The vast majority of the treatment industry has been teaching the 12 steps as the primary approach to 28-day treatment for a better part of the past 50 years. Treatment consists of working the first three steps, learning about the disease concept, defining powerlessness and acceptance, assistance with attainment of an AA/NA sponsor, internal and external triggers and relapse prevention. Why is teaching the 12 steps the focus of treatment when AA does a superb job of handling this responsibility and providing this service for free? The second issue is whether it is ethical to charge for a service that is seemingly free.

A new approach: Addressing core issues in treatment

As an illustration, let’s assume that an addict who has been drinking and using drugs for 15 years enters treatment at age 30. Additionally, let’s assume that this individual grew up in a family system whereby the father worked 90 hours a week, and the mother was a stay-at- home mom, alcoholic and a participant in multiple affairs. Mom was lonely and used the patient as a surrogate spouse and confidant; thus, stressing the importance of maintaining her secrets. Moreover, the patient was a victim of sexual abuse by a neighbor from ages 7-10 and has never disclosed this abuse to anybody.

This patient will enter treatment and AA, with warped definitions of the principles espoused in AA. Additionally, if this individual begins to work steps with their prior definition of concepts such as honesty, faith, courage, willingness and humility, the work they complete will be severely diminished. If the individual’s definitions have been defined via their family of origin, as is the case with most individuals including alcoholics and addicts, how can they be expected to have a foundation for healthy definitions of the aforementioned definitions? The answer, it is impossible! Unless this individual identifies the dysfunctional definitions they have been taught, as well as how these definitions have negatively impacted their lives and thereafter has assistance re-defining these concepts, physical and emotional sobriety will be tenuous.

Re-examining the illustration above, it is likely this individual suffers from issues related to abandonment, trust, lack of healthy attachments, anger and severely warped definitions of love and intimacy; thus, arguably, a host of issues related to the need to numb via alcohol and drug addiction. A question posed by this writer is whether providing an education and teaching this patient about the disease concept and the intricacies of the 12 steps is a valuable first step in treating the patient as opposed to processing the patient’s trauma and abuse (core issues) for the purpose of identification and re-defining dysfunctional and destructive definitions of life. The first approach seems to put the cart before the horse and quite possibly has been a root cause of poor treatment outcomes of treating substance dependence. Additionally, this approach creates a revolving door of repeat business-beneficial to the industry and potentially life threatening to the patient. The latter approach, that of defining dysfunctional core issues, re-defining these issues/ definitions and thereafter or simultaneously incorporating the 12 steps seems to provide a much more comprehensive approach; thus, providing more successful outcomes.

Opposition to treating Core Issues

This writer was recently involved with a peer-peer review with a large insurance company seeking additional days of treatment for a patient. The patient is an 18-year-old female that has a history of suicide attempts, self-harm behavior, sexual abuse from the ages of 8-10 and Opioid dependence. Additionally, she completed 60 days of inpatient treatment without addressing issues related to trust, abuse, self-love, vulnerability or abandonment; however, she did work the first three steps of Alcoholics Anonymous, obtained a sponsor and began writing her fourth step. Thereafter, (within two days of departing inpatient treatment) she was injecting Heroin.

This writer was discussing the patient with the physician from the insurance company who stated, “We don’t suggest that you take the patient that deep, she is only in partial hospitalization and intensive outpatient treatment for the purpose of acute stabilization!” The physician continued “If the patient’s family believes that she needs additional psychiatric assistance, it would be appropriate for you to discharge her from your program and have them place her in a psychiatric facility, although, they would probably need to pay out of pocket.” The lack of connection between core issues as a root cause of substance dependence creates a fallacy that treating substance dependence is as simple as removing the substance (acute stabilization). If this were a reality, it would only be necessary to place the patient in detoxification and that should be the end of the problem. Good luck with that approach!

Another argument against treating core issues as a root cause of substance dependence is “the patient isn’t emotionally ready to handle these issues, let’s get them sober first.” If the direct cause of a person engaging in addictive behavior (alcohol, drugs, sex, relationships, gambling etc.) is to avoid pain and dealing with abuse and trauma from their past, how can you “get them sober” absent addressing the direct cause of the problem. Alcohol, drugs, sex, relationships etc. are the solution to the problem, not the problem. The theory that an individual should deal with one addictive issue at a time has proven to be a dismal failure. If all of the substances (drugs, alcohol, sex, relationships etc.) are a means of avoiding the pain of the core issues, how will the person ever get well merely dealing with the faulty solutions, one at a time, as a means of solving the problem, given that the patient will substitute one addictive behavior for another as a means of avoiding the problem.


In summary, the present approach to substance dependence is a failure. The absence of a true multi-disciplinary approach that addresses biological, social and psychological issues, coupled with a twelve-step approach, is a set-up for a revolving door into present day treatment and the ultimate failure of the patient to get well. It is time that professionals in the industry stop accepting failure as the only means of treating an individual suffering from substance dependence.

David Kolker is a Licensed Clinical Social Worker and a Juris Doc- tor. He is the Clinical Director/CEO and primary therapist at Sober Living Outpatient. He thrives on working closely with clients and watching them grow as individuals. David is published in the area of evidenced-based therapy and specializes in family dynamics and relationships as they relate to recovery.