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What An Alcohol and Substance Abuse Treatment Program Might Look Like

Mark Dombeck, Ph.D.

An idealized treatment program for someone who is alcohol dependent might look something like the following:

  • The patient is identified as alcohol dependent and is sent to a rehab program where they are safely detoxified with benzodaizapines, introduced to AA and encouraged to participate, and asked to participate in individual and group psychotherapy (which might include supportive, relapse prevention, and interpersonal/growth components). He may also be placed on a drug like Antabuse to help him refrain from further alcohol consumption.
  • Three to four weeks later, the patient is discharged and returns home. A family member has removed all traces of alcohol and alcohol-related materials from the home prior to the patient's release.
  • The patient keeps an appointment with a counselor that was made for him before his discharge from the rehab clinic. The patient and this counselor get along and agree to weekly meetings. The
  • The patient follows up on the recommendation that he attend AA meetings. He finds a regular meeting that he likes, and finds a more stable recovering alcoholic person at that meeting to sponsor him. Together, they help the patient work the steps of alcoholics anonymous.
  • The patient is able to remain sober for days, then weeks, then months, then years (all one day at a time) and ultimately goes on to be a sponsor for addicts new to recovery.

This description is idealized because, in the real world, there is almost no chance that the process would go so smoothly:

  • The patient might dislike the process of AA, or be so shy that he won't go, or fail to connect with a sponsor
  • The patient might fail to connect with a counselor and not benefit from continuing professional monitoring and help.
  • The patient might lapse back into use, and be so ashamed of that fact that he continues to use.
  • The rehab might drop the ball on making aftercare appointments for the patient, or the patient might not follow through on appointments that are made

In the real word, the treatment picture is much less like the 'straight line' illustrated above, and a lot more circular. Typical drug and alcohol dependent people start and stop treatment multiple times before they are able to sustain any lasting sobriety. It is important for recovering people to keep this in mind.


Reader Comments

Realities - Alex Brumbaugh - May 28th 2010

Our mantra is, “addiction is a disease.” But (to use the parlance of our day), “Look.” It is different from other diseases. Persons with other diseases generally seek medical care when their condition becomes symptomatic. Not the case with addiction due to stigma, denial, hopelessness, fear, impaired judgment, etc. Additionally, no other disease has the level and extent of co-lateral/underlying/ensuing damages – medical, psychiatric, social, legal, etc. – whose resolution is usually tantamount to successful remission. Finally, while some level of patient participation is helpful and even required for successful remission of some other diseases, successful, long term recovery from addictive disorders uniquely depends in most cases upon ongoing, patient-initiated activities and involvement with non-medical, non-professional, indigenous community resources. In fact, a statistically significant number of people with addictive disorders achieve successful recovery with these indigenous resources alone, requiring no formal treatment, and still others achieve total remission with no outside help whatever (“maturing out” or “spontaneous remission,”), which is highly uncommon with any other chronic illnesses. Is it any wonder that so many disciplines and factions claim expertise? To get good outcomes (tantamount to closing the gap), I think (see we need to figure out what it will look like if we embrace and respond intelligently and appropriately to all of these realities.


I have lived with an alcoholic for 23 yrs. This disease has literally destroyed our hopes and our dreams, not to mention my mental health due to stress. I was a great enabler. I worked myself into an anxiety fit trying to make everything just perfect in my home , spotless , the perfect dinner, kids clean and well cared for. I worked full time 12 hr shifts (rotating) for 10 yrs. Barely getting by on 3 or 4 hrs of sleep most of the time. I thought our children were being well cared for while I was working nights. Years later I find out all the near misses that occured during those times. I was mortified. I have since found god after a lengthy bout with depression, a great psychiatrist and celexa (antidepressant)  and two carpal tunnel wrist surgeries and a hernia repair surgery. I now have learned to forgive my husband for most of the verbal abuse inflicted upon us. All the neglect, the dysfunctional life we created due to his illness. God has given me a new heart and a new mind. I no longer expect him to make me happy, or to meet all of my needs. God is the only one that can make me happy and give me peace. I pray that god brings someone into my sons life to help him understand his fathers disease. So he can also forgive him for not being the father he so desperatly needs. His father now drives drunk regularly although not with my kids anymore. Thank god!  I am afraid he is going to kill someone . He will not listen. A drunk driver smashed into my parked suv last year, his good friend nearly died in a car accident with the driver being drunk. And still he still does this. All a person needs to do is ask god to come into his heart and remove his addiction. I have witnessed miracles in my church. My pastor is a recovering heroin addict 35yrs sober.  Our deacon 15yrs sober. He is a alcohol/drug counselor for our county.    To god be the glory  amen!

“Alcoholism Isn’t What It Used To Be” - Ray Smith - Jun 10th 2009

The largest study yet, "close to 43,000 Americans across the entire demographic spectrum for eight years" says that we've been going at it all wrong:

“Only 13 percent, or roughly one in eight people who develop alcohol dependence, ever receive any kind of specialty treatment in their lifetime,” says Dr. Willenbring. “If you define help-seeking so as to be very broad and inclusive — for example attending an AA meeting, talking to your minister, talking to a counselor or therapist, or talking to a doctor or a psychiatrist — only 25 percent ever seek any kind of help from anyone during their lifetime. That means that 75 percent don’t.”

“One of the big surprises was that 72 percent of people develop alcohol dependence at some point in their lives, and have a single episode of alcohol dependence that lasts on average three or four years,” says Dr. Willenbring. “And then they remit and they don’t relapse — ever. Only 28 percent have recurring episodes. People with recurring episodes have, on average, five episodes of decreasing length. So that really flies in the face of what most of us have thought for many years, and certainly what’s taught in treatment programs.”

Editor's Note: Good find Ray.  Thanks for posting. 

program for dual diagnosis - Ray Smith - Jun 7th 2009

I was just reading the article by Simone Hoermann, PhD on personality disorders and addictions. It showed great insight to the realities of dealing with the dually diagnosed.

I checked out where she works (at a Columbia University affiliated psychiatric hospital), their dual diagnosis program sounds excellent:

I wish there were more around like that. Yes, I'm sure that it is more expensive than 12step treatment, but I'm certain that a cost/benefit analysis would show which is more effective. 

To each his own - Barbara - Oct 5th 2008

people recovering from alcohol are wounded and often spiteful of those proffessing to make it all better. I have experienced many good AA meetings as well as many not so good. The trick is to keep an open mind, don't take anything that anyone says as gospel and work your own program. AA is not meant to be the cure all for everyone. Just as there are endless different personalities in the world so are there endless ways to recover. AA is there so that you don't have to feel alone and if anyone condems you for anything while you are at a meeting then you are at the wrong meeting! Peace.

AA can be harmful to the mentally ill - Kimberly - Jul 3rd 2007

Most members of any AA group have not experienced clinical, biochemically-based mental illness, either firsthand or in someone whom they know well. Nevertheless, they appear compelled to offer all kinds of (very poor and potentially damaging) advice to those who admit to severe mental illness, discuss suicidal ideation in an AA meeting, or refer to themselves as "dual diagnosis" members.  The "advice" of most AA members is probably well meant (though it certainly provides them with ego support as the conferrers of "advice" and "solutions" to other members - something the alcoholic appears to have greater need for than the non-alcholic), but this misguided advice to a very vulnerable population is potentially very damaging, even lethal.

Nearly all non-mentally-ill people (including AA members) have experienced some kind of garden variety situational depression or despair leading to suicidal ideation at some juncture.  This can be especially true among alcoholics because alcohol is a depressant; it also causes substantial problems in people's lives which commonly do lead to bouts of "normal" (non-mental-illness) depression, such as divorce, loss, financial problems, etc.  Because these people have had "bad" or "blue" days, or because they spent some time in grief, or because they thought about suicide at moments when feeling trapped by their addiction, they tend to see themselves as a kind of "expert" on mental illness, even though they are not mentally ill (in the DSM diagnostic sense) and have no education, training, or even personal association with clinical mental illness.  They lump it in with their own bad days or moments of despair, and they think they have all of the answers.

These self-designated experts will hold forth for hours in AA meetings, giving advice to the depressed or suicidal person that is patently ridiculous in emergent situations: you do not tell someone with a suicide plan in his/her head to "think positive" or to "turn that frown upside down!"  You don't work to persuade him/her that he/she just isn't trying hard enough/praying hard enough to a Higher Power/reading AA literature, etc.    These AA members often discourage the mentally ill person from seeking (or continuing with) medical intervention in the form of pharmacology and counseling.  They attempt to persuade the mentally ill person that if he/she just works the 12 steps of the AA program, his/her mental illness will go away along with his alcoholism.  All this does, often, is to reinforce in the mentally ill person's mind that he/she is so abnormal that when even these kind suggestions (which are of course of no avail) don't work, it must be his/her fault, and he/she may begin to experience even more negative thoughts and a diminishment of confidence.  If, after all, these little "remedies" suggested by other alcoholics for "positive thinking" and "prayer" haven't relieved the mentally ill person's depression, anxiety, panic, or what-have-you, then even more despair can set in.

 I learned tonight at an AA meeting that I man I knew very briefly, committed suicide last week.  He was clearly suffering from profound clinical depression (and being treated for it by the VA hospital, though not very well, owing to their cost-cutting prescription formulary and other limits to appropriate care).  He needed different treatment.  I gave him the business card of my own psychiatrist, who specializes in biochemical disorders.  I don't know if he ever made the call.  What I do know is that he, like me, was subjected through AA to the frustration of listening, week after week, to people who know nothing about mental illness holding forth, making poor suggestions, insisting that members refuse all psychiatric medications, and affirming that depression and other kinds of mental illness are "all in your head" and must be approached with "mind over matter" and "positive thinking" and "prayer".  I am not saying that any of these suggestions is harmful, but they trivialize the true severity of mental illness and perhaps keep at-risk mentally ill persons from seeking the help and medications that they need.  This suicide cannot be blamed on AA, of course, but AA certainly did nothing to help this person -- they couldn't, they're not experts and have no training -- but they should have stopped there.  They should no more be giving advice to the mentally ill than they (presuming members are not MDs) should be advising diabetics, heart patients, cancer victims, or any other group from a base of ignorance.


after 21 years in aa - - Apr 23rd 2007

Need rehab? Think about outpatient therapy first. After many years in "the last house on the block"-- AA-- thinking i was a hopeless alkie in with no alternatives I finally got mental health care, and realized aa was not helpful to me anymore, if ever. There is a suggested way to see if one is a "real" alcoholic. Since AA seems to be the accepted referral and cure-all for almost anything now , it's own Big Book's instructions on p. 31 are usually overlooked. The "jitters" seems to be a very important symptom of the "disease". It is the only so-called disease for which so many professionals have embraced the praying, faith-healer's, 12step cure: "God could and would if HE were sought". Drunks seem to quit on their own. Then some of them--not lots-- really do respond to spiritual paths offered by many churches. That is by accepted dictionary definitions of churches. AA with it's prayers, readings. rituals, meetings, jargon, threats of death or worse, and steps (step 3 says,"...turn our will and our lives over to the care of God...") works about as well as jehovah's witnesses, mormons, or other sects that frown on drinking.

Editor's Note: It isn't (or it shouldn't be) an either/or sort of decision (e.g., either I go to AA or I get mental health care).  Both psychotheraputic/medical and support group assistance may have utility.  It is a good thing that you've sought out and have received help from mental health care.   

Dual Diagnosis - Ray Smith - Apr 21st 2007

Some people do get better in AA, but the chances of that happening if they are also struggling with mental health issues are even less and the possibility of harm increased.

AA has a large vocal anti-medication, anti-therapy faction. Often the suggestions of AA members is at odds with the suggestions from mental health professionals. A person is likely to be more inclined to take the advice of folks in AA who claim to offer friendship and support, people that they are able to see whenever they want and are more or less perceived as equals rather than some detached professional; that's why many mental health teams have added Peer Advocates and Peer Support roles.
Kathleen Sciacca, a pioneer in the treatment of dual diagnosis, found that the needs of the dually diagnosed are not met in traditional 12step programs and had better results using Motivational Interviewing.
Many people with mental illness are forced into 12step treatment and much of their behavior that stems from that mental illness blamed on drugs and alcohol. Sciacca said, "Addiction professionals may believe that mental illness is a symptom or manifestation of substance abuse; mental health professionals may believe that substance abuse is a symptom of mental illness. Neither group is therefore likely to provide effective treatment for multiple diagnosed patients in their usual treatment setting."
Back in 1984, the NIMH estimated that "half of all alcoholics and up to 75% of all addicts" have underlying mental health issues. That was over twenty years ago and yet the treatment industry is just catching on. Dr. Kenneth Minkoff states, "Dual diagnosis is an expectation, not an exception" and "When both Mental Illness and Substance Disorder coexist, both diagnoses should be considered primary."
The mental health professionals view the addictive system workers’ methods of confrontation and detachment as cold and unfeeling, while the chemical dependency professional view the mental health system’s methods of individualized support and continuity of care as coddling. Neither provider adequately provides for those clients with co-morbidity.
Rather than two often competing systems in place today, the move towards an integrated system seems to be the most feasible method of helping as many clients as possible.

Ray's Comments - Mike - Apr 20th 2007

     Is that correct?  AA only has a success rate of 5%?  Why would anyone promote something with terrible results like that, if they are in fact that bad?  I haven't read all the posts here, but that really doesn't sound good.

Might look like? - Ray Smith - Apr 19th 2007

Doesn't sound like any of the five rehabs that I've been to, once they had drained me, the insurance company, or Social Services of all the money that they could, I wasn't worth a follow-up phone call or a second thought.

Rehabs are money makers, a 28-day indoctrination into 12step, they exist to make a profit, helping people may or may not be part of the equation.

AA works for about 5% of the people who walk through the doors, no better than trying to quit without treatment. However, people exposed to AA are five times as likely to end up binge drinking (Brandsma study) and six times as likely to DIE as those attempting to quit on their own, according to George Vaillant, Harvard professor, researcher, and member of AA's Board of Trustees, when he went about trying to prove that AA works.

In (the) Handbook of alcoholism treatment approaches: Effective alternatives , AA is ranked 38th in efficiency of those methods tested. Why is 12step still being pushed? Because it is cheap and gives the appearance that something is being done.

Editor's Note: Ray has posted numerous comments on this website, all negative about AA.  While his own experience with rehab and recovery has undoubtably been negative, keep in mind that your own milage may vary.

Treatment Program - - Sep 20th 2006
1.Detoxify the person 2.Push God on them 3. Teach them that relapse is ok. rinse, repeat