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.

In the late 1990s I begin attending workshops on trauma therapy because I realized many of those who struggle with addiction also wrestled with untreated underlying trauma – sexual, physical, and emotional. It was at one of the workshops that I first heard the name Stanley Greenspan. Today he is known as one of the foremost experts on autism having published over 35 books and many scientific publications since graduating from medical school in 1966. But for me, he has become an instrumental figure in understanding the foundation of long-term successful addiction management - which in a nutshell is healthy relationships.

In an earlier post I described how addictions are about relationships, and that long-term success in dealing with addiction necessitates replacing unhealthy relationships with objects with healthy relationships with people. The key to doing this is realizing that to initiate, develop, and maintain healthy relationships requires developmental skills that become constricted, or in some cases, never develop due to trauma or time spent in addictions. These skills are critical to relating to others in many contexts: intimate relationships, child rearing, work environments, marriage. Yet most treatment programs and self-help groups are unaware of the critical need to assess and treat emotional developmental problems. When they go unaddressed, many continue to relapse and struggle in life without the benefit of knowing what is missing in recovery.

Based on his extensive clinical and research experience, Stanley Greenspan created a developmental framework that I believe is among the very best at helping us understand the essence of what it takes to succeed in relationships, but even more, how to optimize our mental health. The framework, in brief, suggests that emotional development occurs in six sequential steps. This overview paper focuses on infants and toddlers, but in the book The Growth of the Mind, Greenspan details how many adults become stuck at early developmental levels and require developmentally based therapy to catch-up. Unfortunately, many treatment programs and therapists will intervene in ways that never advance emotional development, resulting in a lot of hacking at the leaves instead of getting to the root. In all fairness, I spent plenty of time hacking at the leaves with patients because assessing emotional development and knowing how to do developmentally based therapy is not so easy. In fact, it requires a therapist to be attuned to their own emotional development and have some fairly advanced therapuetic skills. But therapy is not the only way to increase developmental capacities. By doing things out of your comfort zone, joining diverse types of groups, engaging with people in many contexts, and journaling about your emotional world can help. In future posts I will be more explicit about specific things that lead to developmental growth.

To get a flavor of the genius of Dr. Greenspan, here is a very short clip from the documentary film “Autistic-Like: Graham’s Story.” Although he is talking about the early development of his DIR model of intervention for autism, such insights are very appliable to those who struggle with addiction. Because “emotions serve as the orchestra leader for getting the mind and brain working together” it is absolutely critical to long-term successful addiction management that significant energy is invested in understanding, managing, expressing, and acting on the vast array of emotions we experience every day.

Addiciton is among our most significant public health problems, which is why I am so excited that the Obama/Biden Administration has named A. Thomas McLellan to the post of Deputy Director of the Office of National Drug Control Policy. Tom brings tremendous talent and experience as an addiction researcher to the position, and from my experience and discussions with him, will not shy away from speaking his mind and doing what is right for those who struggle with addiction.

His appointment comes at a time when the National Center on Addiction and Substance Abuse at Columbia University recently released their second report on the cost of addiction in our society: Shoveling up II: The impact of substance abuse on federal, state, and local budgets (can download entire report for free!).  In short, “The CASA report found that of $373.9 billion in federal and state spending, 95.6 percent ($357.4 billion) went to shovel up the consequences and human wreckage of substance abuse and addiction; only 1.9 percent went to prevention and treatment, 0.4 percent to research, 1.4 percent to taxation and regulation, and 0.7 percent to interdiction. Let’s hope Tom can change this.

I am often asked what I think about the war on drugs, and my answer is:

The modern war on drugs really began when the Office of National Drug Control Policy (ONDCP) was created in 1988 to deal with the epidemic of cocaine abuse throughout the 1980s. Since its inception, ONDCP has spent billions to battle illegal drug abuse in the United States, primarily pushing three goals: 1) stop use before it starts through prevention efforts, 2) heal drug abusers by getting treatment resources where they are needed, and 3) disrupt the markets for illegal drugs by attacking the economic basis of the drug trade.

In a critical analysis of the effectiveness of ONDCP, Dr. Matthew Robinson and Dr. Renee Scherlen, both Associate Professors from Appalachian State University, conclude that the drug war has been a massive failure. After reviewing six editions of the annual National Drug Control Strategy between 2000 and 2005, they provide significant empirical evidence that ONDCP has not represented the facts about the drug war accurately, often skew statistics to put a rosy face on less than productive results, and in the end, should be abolished.

What then should our policy be? 1) stop saying “war on drugs” as this punitive ideological language does not represent a well thought-out and humane approach to addiction in our society, 2) beef-up our prevention efforts in families and communities using empirically validated risk/protective factor approaches that address a wide range of adolescent problem behaviors, 3) increase funding for treatment, 4) drop the “abstinence” approach to drug abuse as the only viable intervention option and incorporate scientifically validated harm reduction approaches (e.g., needle exchange programs), and 5) decriminalize marijuana for personal use (see Reefer Madness).

This topic reminds me of one of the best movies ever on this topic – Traffic. This clip where the head of ONDCP catches his own daughter doing drugs, makes the point so clearly that a war on drugs is a war against our own loved ones (note audio disabled).

Estimates of the co-occurrence of trauma and addiction are quite high, and depending on how trauma is defined, one could argue that most who struggle with addiction have experienced some type of trauma in their life. In my clinical work, most patients had histories of traumatic events that shaped their life in significant ways, even if their present symptoms did not meet criteria for PTSD. The problem with trauma is that it is the gift that keeps on giving – but often in very subtle ways.

What I mean by this, is that when a person has experienced trauma, not only do physical changes in the brain take place that increase sensitivities to stress, but psychologically a person becomes vulnearable to future traumatic experiences – often experiences similar to the original trauma. This is because trauma is like unfinished business, it desires resolution or completion – or a way to make sense of what happened. What this looks like in everyday life is that a person will continue to repeat similar experiences: a sexually abused child will hook up with adult partners that continue the abuse, a physically abused child may find themselves in situations where they are physically abused as adults - and so on. Although each situation may appear different, the underlying theme is that unresolved trauma plays a role in perpetuating a painful life. Because reexperiencing trauma in different forms is painful, addiction becomes a powerful antidote. Thus the reason why one cannot expect good outcomes from addiction treatment if underlying trauma issues are not addressed.