I understand why Beautiful Boy is a #1 New York Times bestseller. It’s a very moving and insightful account of one father’s journey through his son’s addiction, a journey millions of parents have made. David (the author) does not hold back. His writing is powerful, emotional, lucid, and honest. He loves his son Nic to the ends of the earth, there is no doubt about that. Nic is more than just a beautiful boy, he is everything to David. And why wouldn’t he be, he is his son, even when high on methamphetamine and other drugs. At times I laughed, other times I cried. I did not want to be reminded that as a parent there are limits to my ability to protect my son. But it is one of the gifts of the book.

It is often overwhelming reading David’s account of his son’s addiction, and his tireless pursuit to save him. At one point in the book he asks the question: What would you do if a family member were addicted to this drug? He receives many answers from addiction researchers, drug abuse counselors, interventionists, friends, teachers, and members of Al-anon. He leaves few stones unturned, and in the end, realizes that no one person has all the answers. He must decide for himself how to deal with his son’s addiction (and his own addiction to his son’s addiction). I could not agree more. At the same time, I could not help but get frustrated by some of what he was told, and even more, by what he was not told. Here is my answer to David’s question.

Help for David

• I would utilize the Community Reinforcement and Family Training (CRAFT) approach for dealing with Nic and his addiction. When compared to the two approaches most discussed in the book (Al-Anon and doing an Intervention), CRAFT has been shown in clinical trials to be significantly more effective. In one trial, CRAFT resulted in 64.4 percent of addicts entering treatment compared to 22.5  for Interventions and 13.6  for Al-Anon. I would add that if it were me, I would likely skip Interventions, but utilize Al-Anon with CRAFT since there are many positive benefits to connecting with others who are going through similar challenges.
• For family members and friends trying to help an addicted loved one, the end result is most often perpetual trauma. David at one point says, “I have been so traumatized by his addiction that the surreal and the real have become one and the same.” There are many references throughout the book that support the painful fact that trauma pervades not only Nic’s life as an addict, but his father, family, and likely some friends. It is also a sad truth that good trauma therapy is hard to find, and rarely done to any significant degree in substance abuse treatment. For David, who clearly has engaged in a lot of therapy, I would want to explore the degree to which these therapies sufficiently addressed trauma. I have explored this topic in a paper I wrote about treating trauma, as well as in a section about core issues. Understanding trauma and its treatments are as complex as addiction, if not more so. One of my favorite trauma authors recently came out with a new book that I believe should be read by anyone who has experienced trauma, and in my book, that includes us all: 8 Keys to Safe Trauma Recovery. This is tough work, not for the faint of heart. But something tells me that after what David has been through with his son, trauma work would be a walk in the park.

Help For Nic

• David says towards the end of the book, “rehab isn’t perfect, but it’s the best we have.” I am not surprised he reached this conclusion given that when you go searching for help, it is really the only answer. Treatment works. Research says it does, even if you have to go multiple times. And Nic is a testament to this outcome: he goes to many residential (and outpatient) programs and does well for sustained periods of time following treatment before he relapses. I too believe in treatment, but also believe strongly that current treatment practices fall short of what is possible and necessary for long-term success.
• This entire website is dedicated to helping you understand the solution to addiction. My answer for Nic (and David) is summarized in the top five things you should know about addiction and the solution to addiction. David is right when he says in the book that there is no one right path for anyone, but there are specific things that can make a difference in whether a person continues to go through life cycling in and out of treatment, or progresses beyond their addiction.
• For Nic, among the most significant factors that will likely influence his future outcomes is the degree to which his developmental deficits and constrictions are addressed. Among the best frameworks for understanding how to assess development is Stanley Greenspan’s six developmental levels (or stages) of the mind. The deficits and constrictions resulting from early traumas, as well as drug abuse, can be healed over time utilizing developmentally-based psychotherapies. Although meth and other drugs of abuse can result is significant brain changes that impact emotional development, this type of therapy is really the best we have. Unfortunately, in my experience, it is not taught in graduate schools, is completely unknown in residential treatment facilities (and even if it was known, the therapy is done over years, not months or 28 days), and requires significant skill in delivery. It also is the right therapy following trauma resolution work. The good news is that there are some gifted therapists in most places that can do it, it just may require some effort finding them.
• David correctly writes that his son has a chronic, relapsing medical condition that will require long-term care. Yet sadly, it appears that Nic’s care has suffered from our treatment system being a patchwork of acute-based programs, where aftercare is self-help meetings and ”working a program.” Nic needs to stop going in and out of treatment, and instead engage in treatment for many years. The evidence is in the book. When he is in treatment and working his program he does very well, until he stops working his program and relapses. “Working a program” is a 12-step construct that does not include the work I believe is critical to long-term success (see previous bullet point). Staying in treatment for years makes sense when you understand that it is outpatient (not residential), involves resolving underlying drivers of addiction like trauma, is adapted to changes in development over time, and includes the exploration of more than just pathology, like the idea of Me to We. If we are to successfully help people move beyond addiction, we must get outside the black box of traditional addiction treatment and utilize what we know from a variety of fields (e.g., systems science, positive psychology, ecopsychology, education). We can and we must do better, for Nic, and everyone else that suffers.

I want to add that Nic published his own book about his experiences abusing methamphetamine and other drugs, called Tweak. I look forward to reading it in the near future, and hearing his side of the story.

One final comment is related to how David ends the book. He says “I believe we need an all-out war on addiction modeled on the war on cancer.” He goes on to suggest what such a campaign would look like, the funding it would require, and the benefits it could bring. He adds that a research network like that set-up for cancer could test out many promising addiction interventions, including new medications. The good news is that it has been done, and has been bridging the gap between practice and research for many years now. It is the National Drug Abuse Treatment Clinical Trials Network. Check it out.

There are many things I struggle to manage in my life, including time, food (or more correctly my weight), exercise and making sure my dog gets her heart medicine every eight hours. I have other vices as well, but what links all of these things together is that they are ongoing issues that come and go in my life. At times I eat healthy, exercise regularly, and use my time well. Yet at other times I find myself scarfing down junk food, skipping workouts all together, and feeling like a mouse on a never-ending treadmill.

Addictive behavior is similar in that it also comes and goes to varying degrees over time, it is not a constant. Although some can find permanent solutions to end particular behaviors (“I just stopped smoking and never went back to it”), for most people, even if one behavior goes away, another usually takes its place perpetuating the problem of addiction just in a different form. Because objects of addiction can also come and go, it is easy to see why dealing with addiction can become so hard – different addictions, different times, different problems, but most often sharing many underlying traits. As a result, I believe that the most humane way of dealing with addiction is by utilizing a management approach that aims to decrease harm for all behaviors over time, and improve ones quality of life. Too often I see people going in and out of treatment, attempting desperately to put a lid over the behavior and banish it forever, only to get depressed and frustrated when it returns in its original form, or surfaces in another addiction. So how do we manage behavior? Whether it’s addiction or giving my dog her pills, I have found four key things that make a difference:

Awareness: You cannot manage anything if you are not aware of it and how it plays out in your life. Awareness is not so easy these days because we are bombarded from every side with people vying for our attention. But you must increase your awareness of the behavior you wish to change if you have any chance of success. How do we do this? (1) utilize reminder messages on your computer, phone, on sticky notes, put them on electronic calendars that email you reminders, set alarms to go off at critical times, (2) talk with someone about the behavior on a regular basis and process your progress – could be a therapist, friend, pastor, mentor, coach, spouse – who does not really matter so much as just having an ongoing connection and doing it, (3) utilize a form of meditative practice to help clear away psychic junk and make more room to help you stay aware of what is truly important to you, and (4) set-up your environment in such a way as to increase awareness: find new routes to work that avoid high-triggery places, get rid of the extra refrigerator in the garage where you store beer, add things that you want to focus on instead of the addiction like an easel for painting, a musical instrument, or perhaps a pet if you don’t have one.

KISS: Yes, the tried and true Keep It Simple Stupid (OK, maybe the stupid needs to go) applies to managing behavior change. The more complicated you make it, the less likely you will succeed. Simple means we don’t try to change too many things at once, and we do our best to find the simplest and easiest way to accomplish our goal. Earlier this year I significantly changed my diet and felt great. More energy, better sleep, all the things promised from this new way of eating materialized. Yet a few weeks later I was back to my normal, disappointed that I could not maintain what I started. But I shouldn’t have been. I changed too much too fast. We humans live so much by habit, and the many routines our brains lock into very often determine our behavior even when we desperately want to behave differently. In a recent post I mentioned how the environment also sets us up, particularly for making it difficult to eat healthy. We have to be begin by making small incremental changes that support new brain connections, new habits. Change is a process with many different drivers, the key is finding the one that works best, and just staying on the road.

Statistics. For many statistics is a foreign language, existing in a country you never want to visit. But in truth, we live statistics every day of our life. We read sports statistics, check weather reports, listen to stock updates, and hear percentages thrown around in the news. Statistics is the science of making effective use of data, and in the case of managing behavior, there are many things that can be helpful to track over time: days abstinent, relapses, weight, money lost, time spent on particular activities, etc. We track things because of our limited ability to keep a lot of this in our head, to remember the specifics. Keeping a record of progress provides a clear indication of how well we are staying on the road. It provides us feedback that is critical to successful change. Our tracking methods can be as simple as keeping a tally on a notepad, or creating more elaborate outcomes on spreadsheets. I have seen a number of those struggling with addiction get very caught up in statistics, particular days abstinent, where relapses become devastating events instead of opportunities for growth and learning. Statistics should always be used to help us grow, learn, and better manage our behavior over time.

Social Support: You’re aware of what you want to manage, you put a program in place that is simple, easy to stick with, and does not change too much too fast, and you begin to track your progress. The final key and perhaps the most important is understanding that managing any behavior change we make is embedded within the social systems in which we exist: family, school, work, clubs, self-help groups, church, sports, neighborhoods. We are social creatures by nature and influenced greatly be those around us. Successful change requires taking stock of our social connections, both those that support our change and are positive, and those that clearly contribute to perpetuating problems we wish to stop. I have said many times that addictions are ultimately about relationships, and the goal is to replace unhealthy relationships with objects with healthy relationships with people. This is an ongoing process of learning how our past relationships influence our present ones, and how we can heal past wounds and emotionally mature in a way that allows to both receive and give love.

As we begin a new year (and a new decade), many of us will set goals to better manage behaviors in our life. Whether the desire is to reduce drinking, drug use, or have a more fulfilling relationship with food or sex, we stand a much better chance of succeeding when we utilize the above four keys. Happy New Year!

Change is tough. Really tough. Whether dealing with an addiction or making a change in an organization to improve treatment, we are wired to keep doing the things we have always done and resist the new. My last post provided an academic framework for how we should get evidence-based practices commonplace in real-world treatment and educational settings, but doing so often means going against the grain – big time! It means being a change agent in an organization that often does not want to change. It means knowing you have science on your side, and continuing to work at breaking down the walls of ignorance – even when all your peers seem to be against you. Why? Because those who struggle with addiction deserve the absolute best when it comes to treatment and getting help. And when they seek out help from those who are not aligned with science, the outcomes simply are not as good. 

A collegue of mine a few years into her work as an addiction’s counselor emailed me recently about her efforts to enact change within her organization:

“With regard to my attempts to enlighten others on topics such as housing first initiatives and pharmacological treatment for alcohol dependence, I am finding that scientific findings are no match for anecdotal evidence based upon meaningful personal experience.  My colleagues/superiors are either entirely skeptical or they simply minimize the validity of addiction interventions that are non-traditional or abstinence based.  The resistance seems to derive from defensive beliefs that the research methods are somehow flawed, the purpose and designs are somehow biased, and the results are somehow over-inflated, over-reported, or just misinterpreted. It is so disheartening. Beyond that, there is the very real challenge in finding funding for medications and housing. I was also told I have to terminate a client who continues to relapse though I adamantly oppose.  My attempts to advocate for this client with, I believe, sound rationale are ignored and viewed as my unwillingness to accept supervision, etc.  All of this leaves me quite shaken.  Yet I love working with the folks I work with.  For now anyways.”

It’s no wonder that the turnover rate for addiction counselor’s is higher than in the fast food industry! Not only is it challenging helping patients, but the job is made even more difficult when working in organizations that resist change, resist embracing findings from research, and fail to acknowledge the limitations of personal experience.

So what to do? We need to be smart about how we go about making changes, in our life, and in organizations. We need to be aware that change is a process, often with many underlying factors that can influence outcomes. And we need to recognize what science tells us about change. This includes understanding the limitations of the widely adopted Stages of Change Model (see #11).

If you are contemplating a personal change, you might benefit from reading The First 30 Days by Ariane De Bonvoison. A very readible approach that focus on optimism and eliminating fear. If your challenge is implementing change within treatment organizations, a great place to start is The Change Book – A Blueprint for Technology Transfer and the Change Book Workbook.  There are other great resources specific to personal and organizational change, but the key message is that it is a lot harder than people think. It takes perseverance, commitment, and discipline. I applaud my colleague for continuing to push what is right her treatment organization.  

Each year our government spends approximately 95 billion dollars on research to develop new treatments (medical, behavioral, psychiatric, addiction) and about 1.3 trillion dollars a year on actual services to patients. Yet sadly, less than 1 billion dollars a year is spent on understanding how to take what we learn from science and research – the new interventions - and implement them in practice. The result is that many opportunities are lost to help people who struggle with a host of problems, including addiction.

Fortunately, there is increased momentum to study implementation science and learn how to get the latest treatment discoveries to the front lines – to the clinicians who can make a difference in people’s lives. The movement has been led by Dr. Dean Fixsen who heads The National Implementation Research Network. There is a goldmine of information on this site, including a synthesis of implementation research that can be downloaded for free. What I find most interesting from this work is:

• We know from a lot of research what does not work. For example, training alone, no matter how well it is done, does not result in successful implementation of new innovations. Sadly, this finding has significant implications in the academic arena, where teacher lectures account for a large percentage of class time.
• Having a toolbox of evidence-based practices for addiction, as we do today, is one thing, but getting clinicians to use the various evidence-based tools is an entirely different thing. My dissertation research on use of addiction medications provides evidence for this fact. 
  
• Implementing a new practice or innovation requires a number of specific drivers, diagrammed above from a presentation on the NIRN website. Notice that implementation is a process, not a specific point in time, and it involves individuals at all levels of an organization, dedicated to learning and refining new actions.

This topic also has a lot of relevance for individual treatment. Learning to manage chronic behaviors, resolve underlying core issues, and engage ones creativity requires implementation of specific actions. This is why therapy is also a process – a collaboration between patient and therapist who work together over time to learn how best to incorporate new  behaviors into the patient’s life, and stop or limit unhealthy behaviors.

Writing about implementation science reminds me of an earlier post I wrote about making addiction education stick. To increase the chances that new ideas take hold, whether in an organizational context or in individual therapy, we must make our interventions sticky. To do this we must tell stories, boil down complex issues to their essence, be unexpected in our delivery, and make things concrete so understanding is enhanced.

In the end, there are no short cuts to implementation. Remember Wexelblatt’s scheduling algorithm. When implementing an innovation you can pick any two out of a possible three choices: cheap, fast, good (i.e., it can be done cheap and fast, but not good; fast and good, but not cheap; or cheap and good, but not fast). Take your pick.

A comment from a previous post suggested I watch a documentary titled “Cracked Not Broken” by independent film maker Paul Perrier. It was time well spent. In short, the film is about a woman named Lisa who is addicted to cocaine and works as a prostitute to support her habit. Much of the film is an interview with Lisa in a hotel room, where she honestly and openly talks about various aspects of her life on the edge – or as she calls it “the game.” I love how the film goes from black and white to color as she feels the effects of the cocaine she has just injected into her body (yes, there are some graphic scenes). It also shows that despite a number of treatment espisodes, Lisa continues to struggle with relapse hitting home how we understand addiction today – a chronic, relapsing brain disease.

What does Lisa need to successfully move forward in her life?

• Healthy intimate relationships. Cocaine and sex have become more important than relationships – more important than her daughter, her friends, her family. Ultimately, for her to heal, she needs deep emotional connections to those she loves and cares about. For her to have sustained, healthy emotionally-fulfilling relationships, will require that treatment and intervention place increased emphasis on helping her understand her emotional world in a safe way, and developmentally addressing her emotional deficits and constrictions .
• Trauma resolution.  Just watching Lisa in the video you can sense the chaos and trauma in her life. The splitting off and not letting herself feel is classic trauma. I have blogged about trauma being the gift that keeps on giving (although it is hardly a gift), and for Lisa to move beyond her addiction will require significant trauma work. Again, this is where traditional drug treatment programs often fail clients. They may diagnose PTSD, but rarely have the resources, time, or expertise to address it sufficiently. For someone like Lisa, this work likely will require many months (or years), but usually never happens because of short treatment stays. 
• Medication. Addiction is a brain disease, and as Eric Nestler (Professor and Chair of Neuroscience at Mt. Sinai) has so aptly put it – one that hijacks the brain with a force almost unheard of in our natural world. As a result, for Lisa to succeed, she will likely need some medication to help her with cravings, depression, anxiety, and other symptoms associated with her long use of cocaine as she slowly engages into a life without drugs and sex. The HBO series on addiction has an excellent segment on relapse from Anna Rose Childress where she explains why the brain is so vulnerable to relapse. Her example in the film is a guy who is addicted to cocaine and reminds me a lot of Lisa. Dr. Childress even talks about an experimental medication for cocaine abusers that dramatically reduces the brain activity associated with craving (baclofen). Lisa would also likely benefit from medications that reduce some of the hypersensitivities around her trauma, allowing the critical therapuetic work to progress more rapidly.
• Creativty. Actually, her willingness to be interviewed for the film, and share her story with others, taps into her creative side. She wants something “good to come from [her] addiction” and long-term success will necessitate that she continue to find ways to make meaning from her prior life experiences. Writing, singing, becoming a counselor, working with youth, helping other woman get off the street – these things become catalysts for turning shame into meaning.

As an afterword, there is a website dedicated to the film where Lisa had a blog – one that ended on 10/20/08 with her having been through treatment and acheiving over a year of abstinence. She said she is going back to school to become a social worker. Since the blog entry, I can find no updates on how she is doing. My hope is that she has connected with a  long-term solution that leads her permanently away from addiction. Godspeed Lisa.

Years ago I worked as an assistant for two neuropsychologists, essentially doing all the face-to-face testing. Usually, this meant 4 to 6 hours crammed into a small stuffy office conducting various cognitive, memory, and intelligence assessments. Although watching patients attempt to stick square objects in round holes had its moments, the lessons I learned about brain functioning have been very influential in my work with those who struggle with addiction. Here are three of the most important lessons I have learned:

• It’s not intelligence that matters so much as the level of emotional development. I will never forget a couple who were in the process of divorce and both required by the court to submit to neuropsychological evaluations -something to do with custody issues of their children. The husband went first and scored so high I believe he was in the range of genius -it was the highest IQ score I had ever seen in my two years of doing testing. The next day his wife came in and I was unprepared for her IQ score being half of his! In fact, it was clear she had some learning and developmental disabilities. I immediately began to wonder how these two people with drastically different levels of intellect could remain married for over a dozen years. Upon further reflection, I realized that intellect is not the glue that attracts or holds people together, it’s their level of emotional development. I have wrote about this in other blog posts, but continue to bring it up because it points to the absolute necessity of helping those who struggle with addiction developmentally catch-up from the emotional age at which they are stuck. There are some really smart people that get caught up in addiction, and often they can be among the hardest to treat because they believe they can think their way out of the problem. But you cannot “think” your way to a higher level of emotional functioning.
•  The brain needs time following detoxification to heal before it can absorb, process, and benefit from information discussed in treatment. Advances in neuroimaging have helped establish addiction as a brain disease. The slide on the right shows that 10 days post cocaine use, an abuser’s brain is still very far off from normal baseline functioning (top). Even more illuminating is the degree to which brain functioning is still imparied 100 days post last use! We see similar profiles for other drugs of abuse including alcohol, and behavioral addictions. Because neuropsych testing can provide a window into brain functioning, we can use such testing to help us understand how long it takes for the brain to heal to a point at which it is capable of learning, processing, and remembering new information – information such as how to manage addiction over time. Researchers are now doing a battery of neuropsych tests on patients following detox to determine optimal times to begin treatment. What is clear, is that our current system is set-up to have a person who has completed detoxification immediately enter a residential program. About 1-2 months later – about the time they are being discharged from treatment – is really the time when their brain is ready to benefit from treatment. I find it sad that significant sums of money are invested in residential programs when science is helping us understand that for treatment to be beneficial a person must not only detox, but also wait a month or two (or even longer, depending on the drug and time used) before engaging in any significant treatment. This of course brings us the messy question of what should a person do between detox and treatment?  I welcome your suggestions…
• Neuropsychological assessments can be critical for understanding how to proceed with addiction treatment. While working as a counselor at a community-based addiction treatment program, I encountered a number of patients who suffered from Traumatic Brain Injury (TBI). Usually, the TBI would come up in the evaluation, or it would become apparent when I did a mini-mental status exam. Today, over 5 million people live with a disability caused from a brain injury, and approximately 70 percent of those in rehabilitation have a current or past diagnosis of substance abuse. When I first began encountering addicted TBI patients as an intern, I treated them similar to other patients. I did individual therapy, put them in groups, and proceeded to educate them about ways to deal with their addiction. But over time I realized my outcomes were very poor. Many dropped out of treatment,  others continued but were incapable of remembering what they had learned or how to apply it to their life. Relapse rates were significant. Then I discovered our medical psychology department at the hospital and began refering addicted TBI patients for neuropsychological exams. The reports I got back were invaluable in helping me completely restructure treatment. Like children, the trick was understanding what they could comprehend and how best to teach them what they needed to learn. I got a blackboard for my office and begin drawing pictures to represent ideas I wanted to get across. I went slow, paid attention to patients different learning styles, and adapted my treatment approach to the diverse ways in which their brain processed information. And as you might suspect, my outcomes improved. Utilizing the knowledge from neuropsych assessments, I believe, can make all the difference in the world when working with patients with TBI.

I believe basic truths in life get repackaged in unique or creative ways throughout time, resurfacing in books, self-help strategies, stories, movies, or movements. When these things come on to our radar seemingly for the first time, we either embrace them and they become big hits, or we reject or dismiss the ideas because the timing is off - our society is not yet ready.

How to deal with addiction is one of these “basic truths.” Although mankind has behaved in excessive ways for centuries, only in the past couple-hundred years has society evolved the idea of excessive behavior being called “addiction” and requiring intervention. And, only in the past 5 to 10 years has society been ready to accept the basic truth that addictions are problems that we manage over long periods of time, similar to other chronic conditions. In 1955 the book Management of Addictions was published, offering a collection of treatment approaches for alcohol and drug abuse problems. Although the interventions outlined in the book provide significant evidence for how far we have come in our treatments, what I find most interesting is that over 50 years ago a collection of healthcare professionals embraced the idea of “management” in dealing with addiction.

Yet today, we give lip service to addiction being a chronic condition and still largely treat it as an acute problem, where average treatment stays can be measured in days or months. At an addiction treatment conference not long ago, I was frustrated by the complete lack of discussion about how to transform our current acute-based system into one that truly embraced addiction as a chronic condition. It was the elephant in the living room, yet folks went on and on about this ear and that toe…little incremental band-aid solutions to treatment - completely ignoring the opportunity to truly talk about how we might improve care for millions through systems-level change.

I don’t blame them. We have invested a lot in our current system, and many have built careers around the status quo. But the time is right to envision a new treatment enterprise that truly embraces addiction as a chronic condition and wisely utilizes resources to optimize long-term patient outcomes. Idealistic? Maybe so, but the status quo presently sees less than 10 percent of those in need of help, staff turnover in treatment programs is higher than in the fast food industry, and of those fortunate enough to have access to treatment, most do so multiple times. We can and we must do better.

What does it mean to manage addiction? We know manage is a verb that implies action. So, what actions are necessary to get us where we need to be, both with our treatment system and in helping individuals who struggle? Here are a few things to get us started:

• We know multiple treatment episodes are costly because often patients require intensive services (detox, residential, transitional housing, etc.) upon each admission. We should find creative ways to incentivize or reward treatment providers who can keep patients in treatment for years, decreasing costly hospital admissions and residential stays.
• We need to leverage technology and the fact that over 70 percent of folks in the U.S. have high-speed Internet, and many of those who don’t, can still access it now in many public places. Recent evidence suggests that computer-based treatments may be as effective as individual or group counseling. Are human counselors soon to be replaced by robots? Likely not, but there is little doubt that in the years to come computer/Internet-based interventions will play a critical role in healthcare delivery.
• Addiction treatment providers (and patients) should beg, steal (ok, maybe not steal), borrow, utilize, and adapt management interventions from diverse disciplines. Significant research has been devoted to the topic of how best to manage chronic conditions, such as the chronic care model. Let’s not reinvent the wheel, but seek out what others have done, and bring practical, useful, easy-to-implement behavioral management tools to those who need them now.

It’s your turn. What can we do to start transforming our current acute-based addiction treatment system into one that is similar to how primary care treats other chronic medical conditions? What self-management or disease-management tools do you believe are the most helpful? How might we package these tools to make them more accessible to the 90 percent who presently are on their own to deal with addiction?

I know it has been far too long since my last post, but I honestly have an excuse – I have had no time recently to blog. Well, this is not really true, because how we spend our time is based on how we prioritize what must get done. So the more correct answer is - I could have blogged, but other things in my life took precedence.

In the recently published book Rapt: Attention and the Focused Life, Winifred Gallagher makes a case that life ultimately adds up to what you choose to pay attention to. This got me thinking about how addiction has evolved (and adapted) to our changing world, and the ways in which we are all more vulnerable to excessive (addictive) behaviors – or at least exposed to far more triggers or precursors of excessive behavior:

• Food: Not long ago I had the pleasure to hear Dr. Kelly Brownell, Director, Rudd Center for Food Policy and Obesity, speak about the link between food and addiction. In brief, his talk was shocking, sad, and made me really mad. He provided a very empirically-based overview of how the food industry, food marketers (guerrilla, viral, stealth), and chemistry explain a great deal of our current epidemic of obesity. Check out slide 71, where pop manufacturers used baby bottles to package soda – absolutely disgusting!
• Drugs: If the 60’s/70’s were about heroin/LSD/etc., the 80’s were about cocaine, the 90’s about methamphetamine, the drug-object of addiction for our current times is prescription drugs. Why? They are readily available, many believe the myth that they are safer than illicit drugs because they are prescribed by a health care professional, anyone can learn about them online, and we currently live in a culture that seeks quick fix solutions to problems.
• Sex: Advancements in multimedia technologies have been led by the porn industry. Today, anyone can act-out their fantasies in cyberspace through avatars in second life, or find their sexual cup of tea online. Sex also sells products today more than ever, and marketeers continue to up the ante in ads of all kinds. And a day does not go by that some celebrity ends up in the news for infidelity (David Letterman, Jude Law, Ethan Hawke, John Edwards, Hugh Grant, Bill Clinton – need I say more?) Is it all bad? The flip side of the coin argues that what we need in our every day lives is sexual intelligence.   
• Reality Television: The evolution of reality television has resulted in many people spending inordinate amounts of time living in illusory worlds. When people lack the development capacities to initiate, form, and maintain healthy relationships, then relationships depicted in reality shows provide an easy out. We can get caught up in the lives of those we find interesting or are attracted too – their relationships, struggles, and triumphs – and then cheat ourselves of real relationships living only vicariously through those on television.
• Social Networking Websites: Facebook, Myspace, Twitter and other social networking sites have fueled a new generation of social interactions, but research into the depth of social networks today reveals a very sad conclusion: We are becoming more and more isolated in our everyday lives. In a well-designed general social survey comparing social networks in 1985 to those in 2004, the number of people saying there is no one with whom they discuss important life matters nearly tripled! Seems like isolation may be a trigger for wanting an escape…
• Trauma: I continue to be amazed at the degree to which news makers will go to grab the attention of an audience. Traumatic, horrific, terrifying events happen every day, but now they are brought right into our living room in graphic detail via YouTube, Internet news sites, and other multimedia channels. Sure 9/11 changed a lot, but stories about children being brutally attacked, tortured, locked away, thrown over bridges and left for dead, or kidnapped, raped and held captive for years – and that is just the tip of the iceberg – how are we to take-in these violent images and stories? How are we to process them? Make sense of them? Or have we just desensitized ourselves to such stories? And how does exposure to this type of media motivate our desire to escape into fantasy?
• Time: I began this post apologizing for not blogging because of a lack of time. Despite all the new time-saving gadgets I utilize, I still don’t seem able to keep up with the pace of our fast moving society. Fast food, twitter, blazing high-speed Internet, sound bite news, packed calendars, energy drinks, and did I mentioned residential treatment for addictions in under five days? In the book In Praise of Slowness, Carl Honore challenges our way of life in the age of speed. I like both the book and his TED talk because they help us understand how the pace of our society promotes our need for quick fixes, quick releases, and quick highs. Perhaps one solution to addiction is just to slow down life.

William James said “My experience is what I agree to attend to”,  but it seems that we are increasingly living in a world where the choice of what to attend to is being made for us.

Long-term success in dealing with addiction requires more than a focus on pathology and problems. It requires time and attention to building a life worth living, where intimate relationships with people play a crucial role in happiness. It also necessitates a deepening sense of humanity, empathy for our fellow human beings, a sense of wonder, engaging our creative natural talents, and perseverance to deal with all that life throws our way. The actor, Robert Downey Jr., when asked about his addiction not long ago, said:

“Life is 70% maintenance. I think of myself as a shopkeeper or bee keeper. I’m learning the business of building a life. Instead of getting instant gratification by getting high, I push my nose as far into the grindstone as I can. The honey, the reward, is the feeling of well-being, the continuity, the sense that I am walking toward the place I want to go.”

Unfortunately, many who struggle with addiction have no idea where they want to go in life, or what they might want to create. If you are an artist or musician creativity comes with the territory, but for the rest of us -  the power of creativity can remain illusive. One reason is that the process of creating is not taught in our educational system, and in fact, Sir Ken Robinson has spoken out strongly on how our current system actually does the opposite (please watch this amazing presentation – you will not be disappointed). But all is not lost…

Recently, I picked-up a book at a bake sale that brilliantly answers the question of what we should create in our life and how to go about making it happen:  Me to We: Finding Meaning in a Material World by Craig and Marc Kielburger. These two Canadian brothers reveal through their own journeys how a focus on gratitude, empathy, and creating community leads to a life of happiness and fulfillment beyond any material possessions. From their personal encounters with Mother Teresa in the slums of Calcutta, to helping those dying of AIDS in Thailand, to creating one of the largest non-profit foundations for children, Free the Children, these guys provide the broad brush strokes for how to create a life more powerful than addiction. The essence of me to we is that by helping others we help ourselves find meaning and purpose in life – and we make the world a better place. What I like most about me to we is that it ultimately is about creating nurturing relationships with people – exactly what needs to happen if we are to move beyond addiction.

One of my first and most memorable patients was a Native American man who I was treating for alcohol dependence (among many other complicating factors). On multiple occassions, he had been admitted to the hospital for detox with blood alcohol levels that would kill most humans. He could drink a lot, but the problem was he also had a traumatic brain injury that required medication, so with every relapse came the potential for death and need for hospitalization. After months of weekly individuals sessions, and despite frequent relapses, we had an incredibly strong therapuetic relationship – so strong that one day he came in to session and said…

Your approach isn’t working. I know you mean well, but the western way is hard for me to understand. Here is my bible…and he handed me a copy of Seven Arrows by Hyemeychsts Storm. It was one of those valuable early lessons  where I realized that there is no one right path in healing from addiction. Only the path that is right for you. But the story continues…

Months later after reworking our treatment plan around the medicine wheel, he is still relapsing, ending-up in the hosptial for detox, and I am left wondering where I went wrong. Fortunately, my Clinical Supervisor at the time was an insightful, experienced therapist who suggested I review all hospital detox admission records since he first entered treatment to gain some perspective on what was actually happening. Since every relapse had been followed by a hospital admission, I was able to easily complile a graph of relapses over time, and when I did, something amazing materialized.

He was getting better. It was right there in the data. After plotting the relapses on a graph I was able to see that the time between them was increasing – actually doubling with every relapse. What on the surface seemed like failure to me, was in fact – after reviewing the data – success. And why should have I expected progress to be any faster? This guy had years and years of drinking history behind him. Change is a process, and with addiction, takes incredible patience. We also know that addiction is a chronic, relapsing medical condition where relapse is part of the process. When I presented the graph to him at our next session he was equally pleased, and even more motivated to continue the progress.

Six years into our work he had well over two years of sobriety. His relapses continued to decrease in frequency maintaining the pattern he began when he entered treatment. The moral of the story: 1) follow a recovery path that is right for you, 2) track relapses and other significant events because data can provide insight where memory fails, 3) change is slow - patience is key, and 4) relapse, even after significant abstinence time, should be an opportunity for learning and not a time for shame and blame. We all make agreements with ourselves to do things (diet, exercise, New Years resolutions), and we all fail at times. Relapse is not an addiction phenomenon, it is a human phenomenon.