Rethinking Recovery: Where the System Fails w/ Dr. Andrew Tatarsky, PhD
Welcome to Journey to the Sunny Side, the podcast where we have thoughtful conversations to explore the science of habits, uncover the secrets to mindful living, and of course, your own mindful drinking journey. Ever since our first interview, I've come to deeply respect today's guest, and I'm grateful to now call him a close friend. Doctor. Andrew Tatarski is a clinical psychologist, author, and one of the pioneers of harm reduction psychotherapy, a model that's helped thousands of people build a better relationship with substances, even if abstinence isn't their starting point. In this first part of our conversation, we talk about why traditional models, like abstinence only and the 12 step approach, still dominate despite working for only a small percentage of people.
Speaker 1:We explore the history behind those models, how they became the standard, and why that can leave so many people feeling stuck, shamed, or unsupported. This episode isn't about dismissing what works. If you found a path that helps you, that's a win. But we also need to talk about the millions of people who haven't found success with the old playbook and to know there are other options. Let's dive in.
Speaker 1:Andrew, thanks for coming on. In fact, let me say thanks for coming back on the show today.
Speaker 2:My pleasure. It's great to, you know, exchange ideas with you and also with all of the people out there that will be listening to this discussion, this conversation.
Speaker 1:Well, I'm looking forward to it because we've had a lot of good discussions on and off camera and your ideas and your approach to everything is, I think well, it's something that you've put your entire career and life and mission behind because it makes a real difference with people. So I'm really looking forward to getting into that, listening to your insights Mhmm. And hearing more about harm reduction from somebody that actually is practicing this, sees the results, and works with other practitioners that can, first of all, train them, but also go out and bring it to the real world. But let's start here. Let's take a step back because I think this is where many people feel stuck, and that is around traditional models when it comes to substance use.
Speaker 1:So why do you think that this abstinence only and 12 step model, first of all, still dominate even though they don't work for the majority of people? Well,
Speaker 2:I I think the answer to that question is really, really complicated. You know, there's a whole history behind it, and that history had to do with, you know, early ideas in the nineteenth century going into the twentieth century about, you know, problematic drinking or what, you know, was called, I'd put in quotes, alcoholism and then later addiction as being kind of a moral issue. That is drunks were degenerates. They were morally weak. You know?
Speaker 2:And and and there was a whole kind of religious, I think, background to that. So, you know, that was a very powerful influence, you know, in the early part of the twentieth century. Right? And, you know, and then that contributed to prohibition where, you know, it I mean, it sort of supported the idea that, you know, we should get rid of alcohol. I mean, so, you know, a moral issue became a criminal issue.
Speaker 2:And, you know, then and and I don't know if I really should be going into all of this history, so maybe you'll cut this out. But, you know, I was just thinking about that question, you know, that that that there's this whole history that contributed then to the criminalization of drugs, which also I think contributed to stigma. And that that somehow contributed to the mental health profession, you know, in the twentieth century kind of abandoning by and large the treatment of people that struggle with problematic substance use. And then so there's this kind of by abandonment. Right?
Speaker 2:And in that vacuum, AA was born. And even though interestingly, there were some very, very good, mostly psychoanalytic writers that were really writing about problematic drinking or or and drug use as meaningful, which is really almost the roots of a new paradigm that I think has been emerging that I've been involved with. But nonetheless, the mainstream by and large abandoned helping these folks. And in, you know, in the nineteen thirties, AA was born. And AA was not a scientific or professionally led organization.
Speaker 2:It was a peer led organization of mostly white men who came together to support each other in in stopping drinking or addressing drinking problems. And, you know, and so it was actually also based on a kind of a moral issue, you know, character defects, which is this sort of vague concept, I think, unscientific concept. But then, you know, it talks about in the big book that a that alcoholism is a disease of the body and an obsession of the mind,
Speaker 1:which,
Speaker 2:nonetheless, I think as one of the only, you know, approaches that were available to support people, you know, it attracted a lot of people that were struggling, and I think it was very helpful to a lot of people. And back then, it was the only way, right, by and large. Then in the midst of that and there's a whole interesting history to this, you know, the backstory. E. M.
Speaker 2:Jelenick, who was a charlatan, who was not professionally trained as a as a doctor, but he winds up getting himself a position as the director at the Yale Center for Alcohol Studies in spite of the fact that he had no higher education or medical training. Get that. But he befriends, you know, a prominent AA member and he does a study, a survey study of AA members, which is a completely non scientific study. But based on that survey, he writes the disease concept of alcoholism. And so this non scientific book that is promoted by the Yale Center for Alcohol Studies kind of is adopted as the standard view of of alcoholism and more broadly addiction in The United States.
Speaker 2:And so it kind of co opted the addiction treatment field. Right? And so it further, you know, sort of reinforced this split between the dominant, you know, mental health treatment field and the addiction treatment field. Right? So that nonscientific model sort of takes over the addiction treatment world.
Speaker 2:And then so you've got people that are invested in promoting that model because in many cases, it helped them. So they had a personal investment. And I think it's more complicated that the psychological investment in that model also is meaningful. And that for many people, it's defensive. It's a way of avoiding or reinforces avoiding dealing with deeper issues that may be driving, you know, problematic drinking.
Speaker 2:So there's an identity investment. There's you know, this helped me, and so I I think it can help other people. There's a dynamic investment. And then a field that, you know, the addiction treatment industry that grows up based on this model then has an investment in the finance and the business of addiction treatment. So, you know, that really led to kind of a grow you know, a huge field that seemed to be, you know, and promoted the idea that, you know, this was the only way.
Speaker 2:Right? Now we can say more about that, but, I mean, I think that that what's critical about it is also that the disease model of addiction that was earlier, you know, driven or or promoted by EM Jelenick and then later picked up by NIDA, the National Institute of Drug Abuse, who then sort of decided they were going to find the cause of the brain disease that was driving this. These are models that reinforce the idea that, you know, only people who are in the who are addiction treatment professionals can treat this condition. And mental health professionals, by and large, were told explicitly and implicitly that, you know, you can't treat these folks until they get, quote, sober. And that's really what, you know, that disease model suggests as I learned it in the early part of my career.
Speaker 2:Addiction is a permanent chronic progressive disease only arrested by complete and total abstinence. So the model gives rise to an abstinence only ethos that says you gotta get sober in order to be successful in addiction treatment, and you gotta get sober or abstinent before you can benefit from mental health care. And so that model effectively kind of becomes self perpetuating. Right? And and and basically, as you said in your opening statement, that model has contributed to the failure of the helping profession to help the overwhelming majority of people who struggle with these issues who need and want help.
Speaker 1:Yes. Absolutely. And, I mean, if this sounds critical, we are absolutely being critical right now because anything that legitimate or otherwise is always gonna need to have some observation and, critical thinking around the process and whether this is the best way or the only way to do things. And one of the things you mentioned there is that because of that model, it does draw a lot of controversy. Somebody listening right now will absolutely not like some of the things that you and I are saying right now, and we'll get into some of the psychology of why it's so highly disputed as the only way.
Speaker 1:And in fact, you know, we talk about some of the failure rates. It's estimated. Who knows how these stats are are all accurately compiled, but somewhere between eight and twelve percent success rate. Now now others said, saying that another way is, like, around a ninety percent failure rate, but that also doesn't include the people that don't actually feel like the program is for them that then never do anything so that the bar is so high. Mhmm.
Speaker 1:And I'm speaking from my own personal experience. And if you actually say, I don't relate to that, then the actual answer to that is, well, then you're in denial, and you can't be helped until you let go that ego that you have there. What what do we do about these these stats? You know, like, eight to 12%, why is it why is it still being shined on in many respects, although the narrative's changing as the solution for anyone that has any substance use problems?
Speaker 2:Well, I think it's important to say what I imagine you agree with. AA is a wonderful program for a very small percentage of the people that struggle with significant substance use issues. So I am not interested in AA bashing. I am not here to say AA doesn't work. I think the problem is both with many maybe many people's view of AA that it is the only approach that works for people.
Speaker 2:That's the problem. Because then it, by definition, implies that if it doesn't work for you, that you're the problem, not the program. So that's a very dangerous and important distinction.
Speaker 1:I think that's the hardest one for me. You know? Like Yeah. I'm and it's related
Speaker 2:to the disease model that I'm that I mentioned because the disease model, at least Jelenix model, and I think that has implicitly and explicitly pervaded the field that says that it's a permanent chronic progressive disease only arrested by complete and total abstinence. And if you don't believe that, the corollary is you're in denial if you don't accept that. And that is the first step of AA to accept that you are powerless over alcohol. So if you're out of control or you're struggling and you're not accepting it by AA's definition and by that disease model definition, you're in denial. And if you're in denial, you can't make any positive change.
Speaker 2:So that can lead to things like you need to hit a lower bottom. You need to suffer more. You know, come back when you're ready. You're not motivated. So in effect, the patient, client, person gets blamed for not being ready to commit to abstinence and being ready to accept that model.
Speaker 2:Now then there's another corollary, which is really dangerous, which is if you don't as a helper, as helping professional or a concerned significant other, if you don't enforce that well, with with love, really. But if you don't, you know, try like heck however you can to get that person sober or to accept their disease, then you're an enabler. So that leads to the conclusion that, you know, you're just enabling the disease, Mike, if you you know, therapist Mike who's, you know, trying to get that person sober or to accept they need to stop. And the family then gets tagged as sick. The family is enablers.
Speaker 2:Right? The family is as sick as the the person with the so called disease. So, you know, it's a story that can make a lot of people really miserable unnecessarily. And so I think we need to really question these the fundamental assumptions that are in embedded in that story.
Speaker 1:Do you think that some of the resistance maybe to get started with the program, but also the, like, the actual outcomes that we're talking about here. I think a lot of people automatically say, oh, they you know, it doesn't it might not work at a high success because the
Speaker 2:the
Speaker 1:prescriptive the prescriptive path is never to drink again. But do you I've you've obviously thought this through. Is it that they never can drink again Is the failure rate? Is it the process or the accepting of the disease model? Is it maybe something else?
Speaker 1:Where do you see sort of the breakdown that maybe it's not serving quite as many people as we'd like to see?
Speaker 2:Well, what that brings to mind is that I think that most people, at the point that they become concerned about their substance use, and even as maybe substance use begins to become more and more problematic, are not ready, willing, or able to seriously commit to stopping for very good reasons. And and that's the basic mismatch that is a program, whether it's AA or it's a treatment program, you know, that has an abstinence only requirement, is simply not speaking to the overwhelming majority of people that need and want help who are really struggling, but for good reasons are not and and maybe a part of them wants to stop, but they're not there yet, if ever. And many of them don't need to get there. So it's like I I have used this analogy before, which I'm told is very compelling, is, you know, if you decide one day you really wanna commit yourself to getting healthy and getting in shape, You realize you finally realize, I'm out of shape. I'm tired.
Speaker 2:I'm, you know, having trouble sleeping. I'm stressed. You know? And you figure you're gonna go to a gym and maybe find out, you know, what you can do about it. You show up at the gym.
Speaker 2:Imagine they say to you, we'd love to sign you up. And in order to join our gym, you're gonna have to sign up for the marathon, to run the marathon in six months. And in order and in order to prepare for that, we're gonna sign you up for five training sessions a week, you know, with an individual trainer plus classes plus, you know, you know, a whole set of recommendations around your diet and so on. You're ready to sign up. And I bet you virtually nobody would sign up for that program.
Speaker 2:What do they do when you come to the gym? They say, hey, what are your goals? You know? Can I show you around the gym? You know?
Speaker 2:Can I talk about our different options? Can I make some suggestions based on a fitness evaluation for how you might get started? So that's what good treatment is. That's actually what good harm reduction treatment. You know, matching what we offer to people to who they are as unique individuals, you know, where they are motivationally, you know, what's realistic for them in terms of the complexity of their drinking issues, substance use issues, their lifestyle, etcetera, as opposed to, you know, having this, you know, predetermined ideology about the nature of people's problems and what they need to do about it, which I would argue for many people can be even traumatizing and and can contribute to what I've called treatment trauma.
Speaker 2:We can talk more about it if you like.
Speaker 1:I seem to remember from our last conversation, you had a couple things happen to you in your past. One, as a youth that that might be related to treatment trauma, but also, I'm remembering there was a point in college when you realized that this doesn't make sense to me. Like, can you go back a little bit and talk about because there's there's a path to to exactly where you are and what you've been doing, and I think some of those points in your lifetime really contributed to some of these understandings.
Speaker 2:Well, so there's a professional story, and then there was an earlier personal story that I only really reconnected with, really remembered a number of years into my professional journey.
Speaker 1:Okay. That's where we'll pause for today. In part two, releasing tomorrow, Andrew shares the personal moment that changed everything for him and how he developed a radically compassionate approach that meets people where they are and helps them make real lasting change. Whether you're exploring harm reduction for the first time or just wanna better understand the full range of tools available, you won't wanna miss it. I'll see you there.
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