“Addiction in the modern world can be best understood as a compulsive lifestyle that people adopt as a desperate substitute when they are dislocated from the myriad intimate ties between people and groups – from the family to the spiritual community – that are essential for every person in every type of society.”

Bruce K. Alexander, The Globalisation of Addiction: A Study in Poverty of the Spirit

In the previous post I discussed how adverse childhood experiences (ACEs) to a large extent play an important role in the development of addictions. Given that over 80 percent of those who develop addictions begin adaptive behaviors to cope with ACEs prior to the age of 15, we as a society need to place a greater emphasis on identifying at-risk kids and intervening as early as possible. But there is another insidious root to addiction that I believe goes beyond individual ACEs and plays an even greater role in the development of addiction – free market society.

Bruce K. Alexander spent decades as a distinguished addiction researcher in Canada before becoming so frustrated by a lack of progress in helping those who struggle, that he completly changed careers and decided to focus on teaching history instead. Despite doing everything he could to avoid topics around drugs and addiction, the more he studied history, the more he discovered insights that began to change his entire perspective on the nature of addiction.

In general, when we think about addiction, we think about it as an individual problem. Individuals are exposed to a host of risk factors, including ACEs, peer group influences, and the availability of objects of addiction in communities. The more risk factors an individual is exposed to, the more likely the chances are that he or she will develop an addiction. Conventional wisdom also suggests that the antidote to addiction is intervention and treatment. But when Dr. Alexander began studying history, he discovered cultures and societies where common objects of addiction were present (drugs, alcohol, sex, food), yet addictive behavior was minimal or nonexistent. ”Addiction can be rare in a society for many centuries, but can become nearly universal when circumstances change – for example, when a cohesive tribal culture is crushed or an advanced civilisation collapses (Alexander, 2008).” Throughout history, the primary factor responsible for the societal change leading to pervasive addiction is the introduction of free market society. Why?

When a society introduces free markets, exchange of goods and services optimally are not encumbered by family ties, cultural traditions, religious values, or anything else that may impede free play of the laws of supply and demand. In other words, free markets create an “every man (or woman) for yourself” dynamic that puts me in competition with everyone else for jobs, insurance, a house, goods, services and Lady Ga Ga tickets. One consequence of this system is that people become dislocated, or disconnected from one another because of the time and energy necessary to keep up with the Jones. Free markets are incredibly profficient at knowing how to keep people focused on stuff over experiences. Flashy ads, mass media, and the latest gizmo from Steve Jobs keeps us always wanting more. In the pursuit of the American dream, what many get instead is isolation, fear, and dislocation, which ultimately leads to compulsive lifestyles where people develop addictive relationships to stuff and get further and further disconnected from nurturing human relationships.

Dr. Alexander’s Dislocation Theory of Addiction is well documented in a paper titled The Roots of Addiction in Free Market Society (highly recommended reading) and a more extensive read: The Globalisation of Addiction: A Study in Poverty of the Spirit. His work is extremely important in helping us all understand many of our current societal ills beyond addiction, including: divorce, single parenthood, children in poverty, obesity, unemployment, and excessive time in front of the TV. Until we as a society place relationships and experiences over materialism, consumption and stuff, Thoreau’s observation that ”the mass of men lead lives of quiet desperation” will ring ever more true.

What is the solution to mass dislocation? I believe part of the answer lies in making some tough societal changes including ending the senseless war on drugs (a big topic for another time). But for the individual struggling right now with addiction, the answer is much more about restructuring life in a way that emphasizes relationships over stuff. To do this, one must have the developmental  capacities necessary to know how to initiate, develop, and maintain healthy human relationships.

“For every thousand hacking at the leaves of evil, there is one striking at the root.”  – Thoreau

In my life there have been many times when I felt isolated, lonely, disconnected, and alone. These times have never  been pleasant, and in the absence of nurturing relationships, close friends to call on a dime, or a tribe of my own, I coped by engaging in substitute relationships with work, money, entertainment, food, hobbies, and exercise (just to name a few). For years I felt shame about many of my behaviors, and my inability to connect in deep ways with others. Now I understand that so much of my adaptive behaviors were a response to underlying root problems, problems that needed resolving and hampered in significant ways my ability to intiate, develop, and maintain intimate and nurturing relationships with people. I also believe that now, more than ever, those who struggle with addiction share similar root causes that need to be addressed if successful longterm outcomes are to materialize.    

The roots of addiction go much deeper than the adaptive behaviors that so often are the focus of intervention efforts. This is because dealing with the symptoms (addictions) are easier than dealing with the root causes. I have long believed that addiction is a problem best managed over time like other chronic illnesses. But successful management necessitates addressing what drives the addictive behavior in the first place. It requires knowing how to turn down the flame, dig out the roots, and resolve problems that are solvable. These underlying roots come in many shapes and sizes, but there are two forms that I believe are the primary drivers of addiction today. This post will address the first form: adverse childhood experiences.

Adverse Childhood Experiences
In the mid 1980s, physicians from Kaiser Permanente’s Department of Preventative Medicine in San Diego made an interesting discovery. Those who were losing the most weight and succeeding in the weight loss program were the ones most likely to drop out and quit. Was it because they no longer needed the program? Nope. Further investigation revealed that the majority of dropouts did not maintain their weight loss and went back to struggling with problems of overeating and obesity. Why did they quit if they were succeeding in the program? A deeper look revealed that overeating and obesity were used as tools to cope with unresolved adverse childhood experiences (ACEs). In most cases, overeating was an unconscious behavior utilized as a protective solution to these unresolved childhood problems.

How was it unconsciously protective? In many cases, the ACEs involved sexual, physical or emotional abuse. Developing a relationship with food was safer than developing intimate or nurturing relationships with people who might abuse again. Being obese unconsciously deterred romantic interests and physically enhanced protection of the body. The finding that most of the participants in the weight loss program had prior ACEs led Kaiser to collaborate with the Centers for Disease Control (CDC) to explore the link between ACEs and general health outcomes.

The study involved over 17,000 middle-class Americans and has produced over 50 scholarly research journal articles. Among the most signficant findings in the study was that two-thirds of the participants reported at least one ACE, and more than one in five reported three or more ACEs. In addition, the higher a person’s ACE score, the more addictive behavior was utilized as a coping response. For example:

Here you can see that as the number of ACE scores increase, so too does the percent who meet criteria for alcoholism. This finding is detailed in an insightful paper titled The Origins of Addiction by the lead researcher of the study, Vincent Felitti. What the ACE study helps us to understand is that the roots of addiction are real, diverse, and if left unaddressed, will continue to fuel the behavior we are so badly trying to manage (or end).

I recently learned about the website Living Hero that produces podcasts of “living luminaries and mavericks” hosted by Jari Chevalier. Her most recent interview was with Dr. Gabor Mate, a Canadian physician with a broad range of life experience (and wisdom) on topics including: mind-body medicine, stress and trauma, ADD, and addiction. I first heard about Dr. Mate when a close therapist friend told me about his book, In the Realm of Hungry Ghosts: Close Encounters with Addiction. Shortly thereafter, another friend said he had been to Portland and spoke at a college campus. Then…the podcast interview. Call me slow, but eventually I do pay attention when the universe is attempting to tell me something – like pay attention to this guy!

After listening to the insightful interview by Jari (please go listen now), it is clear that much of what Dr. Mate believes is very much in line with the information on this website and blog. He advocates understanding addiction as a coping response to underlying pathologies, namely adverse childhood experiences. These early events impact brain development, as well as other developmental capacities, resulting in the need for relationships with objects that help regulate stress and emotion cycles. Although much of the discussion focused on addiction as a coping response (feel better), I believe Dr. Mate would also agree that addictive behavior is perpetuated because it feels good – the brain likes it!

I remember a case involving very successful business owner who decided to have lunch with her girlfriends at a local diner that just happened to also have newly installed video poker machines. Having no history of gambling behavior, she thought nothing of putting a buck in the machine to see what would happen. Minutes later she experienced a “big win” – a $600 dopamine rush. So…the following week she told her girlfriends they should meet again for lunch at her lucky restaurant. She put another dollar in the machine and amazingly she won the jackpot again, another $600 big win. That was all it took for her brain chemistry to rearrange some important neurons that led to an out-of-control gambling addiction. Her husband brought her to the clinic because she was unable to stop playing video poker, was blowing thousands of dollars per day, and neglecting her business and family. Although she did love how winning made her feel, in the end, her relationship with video poker machines was just another substitute for the human intimacy she so longed for, but struggled to obtain.  

Addiction is a very complex problem with no easy answers. What I like most about Dr. Mate’s approach to healing is that it is humane, sensible, and incorporates harm reduction strategies. More information about his work can be found on his website. But if you can’t wait to read his book, then listen to the podcast byJari, it is well worth your time.

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.

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 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.

Once a year I am fortunate to have the opportunity to teach a graduate level class at the university on the foundations of addiction treatment. And every year I struggle with how best to organize the class time, materials, and lectures in a way that optimizes students retention and liklihood that they will “act” on what they learn. This of course is an age-old topic, but recently two guys, Chip and Dan Heath, wrote a best seller called “Made to stick: Why some ideas survive and others die” that sheds some light on what is important.

They propose that getting ideas to stick , and more importantly increasing the chances that people will act on those ideas, is enhanced when they are: simple, unexpected, concrete, credible, emotional, and expressed in stories (SUCCESs). The book is well-written and provides numerous examples of how these principles play out in the real world.

After devouring the book, I decided to use the principles in my teaching efforts. The results were very positive, as my students reported that story writing (instead of tests) and a final paper based on using class experiences to illustrate the SUCCESs principles resulted in an exciting, fun, and very different class. Whether I can say for sure that the material they learned will be retained and acted upon in the future would require an outcome study that I may consider in the future. 

These ideas can be translated into many settings: teaching, counseling, coaching, translational research, and implementation science. Here is my summary of the ideas applied to addiction: Making Addiction Education Stick.