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.