• Addiction is a problem on the rise all over the world, and the factors perpetuating this problem are similar
• Addiction is a window into our lives, culture, and the many problems we face day-to-day, and thus can teach us a lot about ourselves
• Addiction is an adaptive response to the increasing breakdown in community (dislocation) and intimate social ties necessary for a good life
• There is no formula or recipe for how best to intervene at the societal/community level and reverse the trend of addiction, but we should look to other countries that are further along in their efforts to curb addiction problems (Scandinavia, parts of South America)

Our government is currently very invested in promoting addiction as a brain disease, and the development of medications and psychosocial interventions that can treat the addicted brain. Unfortunately, however successful these interventions may be, they do not move our society in the direction of what addicts so badly need: human bonds, intimacy, and community. What I really get out of listening to Dr. Alexander is a message of Hope that we can change our ways. We can return to a way of life that is more grounded in relationships and not so consumed with materialism.

Also, check out Dr. Alexander’s website and  let me know what you think of the interview!

Now, more than thirty-five years later, I find myself married with a young son and challenged to provide him the same care-free childhood that I experienced. Despite living in a pleasant, middle-class neighborhood, it is rare to see large groups of kids playing together outside. There are no local woods within walking distance, and even if there were, most parents (myself included) would be hesitant to allow their children to play unsupervised. Although everyone I encounter on my daily dog walks is friendly, there is a lack of deep intimacy among neighbors. Some have never even met despite living within blocks of each other for decades.

The stark contrast between life today and just a few decades ago is surreal. The year I was born the handheld calculator was invented, and today, handheld devices are minicomputers capable of video-conferencing around the world. But for all the benefits technology affords, there is a cost that gets lost in the frenzy of Facebook, YouTube, and Amazon.

In 1985, researchers set out to understand the degree to which people have family and friends they can rely upon to discuss matters that are personal in nature. A national survey was done, and in 2004, the same group decided to repeat the study to determine how core discussion networks had changed over two decades. The results are frightening.

• 25% of all Americans in 2004 reported they had no one in their life to discuss personal issues, compared to 10% in 1985
• The modal (most frequent) number of discussion partners in 1985 was three, but in 2004 that number plummeted to zero
• The average social network size has dropped from 3 confidants to 2
• The number of people who reported that their spouse was the only person they trust with personal issues increased by almost 50 percent since 1985

These outcomes paint a sobering picture of the price we may be paying for our technology-enhanced life. The lead researcher has said, “we know these close ties are what people depend on in bad times. We’re not saying people are completely isolated. They may have 600 friends on Facebook.com and email 25 people a day, but they are not discussing matters that are personally important.”

Source: Social Isolation in America: Changes in Core Discussion Networks over Two Decades, American Sociological Review, June 2006 71:353-375

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.

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).

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.

Why do we need it? Because most social/healthcare service organizations are in crisis. U.S. healthcare problems were detailed in a number of publications by the Institute of Medicine, with outcomes indicating that the U.S. has the most expensive healthcare system in the world, yet ranks far down the list in terms of overall quality. But it is not just our healthcare system that is in dire need of overhauling. Our education, criminal justice, mental health, child welfare, and…yes, our addiction treatment system are all struggling to meet the needs of the populations they serve. The Santuary Model suggests that the problems are rooted in unhealthy systems, not individual people. If we understand the system, we then stand a chance of making changes within the system that ultimately translate into better outcomes for all involved.

Across the different social systems, the problems are similar: reduced funding, decreased training and education, more paperwork, more surveillance and  micromanagement, greater staff turnover, and lots of stress across all levels of organizations. These factors then translate into organizations that are chronically stressed, attempting to do more with less, always operating in a reactive/crisis mode, ultimately leading to folks being chronically hyperaroused. In this state, it is like Brian Farraher, CEO of Andrus Children’s Center has said, “Managing like your hair is on fire.”  Stress leads to a loss of basic safety and trust, a breakdown of emotional intelligence, behaviors that result in more conflict, and staff who feel disempowered. As relationships become strained, more autocratic approaches to leadership (counseling/healthcare/justice) emerge, and then folks just stop talking. In essence, organizations stop learning. The outcomes are costly for all involved.

The Santuary Model is the antidote. It acknowledges that stress, trauma…life problems, exist not only in the clients who show up for help (or are mandated for help), but also in the helpers. The served and the servers are mirrors of each other, and both require focus and attention on seven commitments:

Implementing the Sanctuary Model in organizations, and incorporating the commitments into all of our lives, means embracing our responsibility to the common good of all people, to our future, to our planet. The details of the commitments, and how best to implement them are documented on the Sanctuary Website and in Creating Sanctuary: Toward the Evolution of Sane Species.

If we ignore the warning signs so clearly right in front of us, “Human history becomes more and more a race between education and catastrophe.” HG Wells, Outline of History, 1920

Here is my own commentary about sex addiction and Tiger’s problems:

• Far too much time is spent debating whether specific behaviors should be called addiction. The reporters above point out that many do not consider sex addiction a real psychiatric disorder because it does not exist in the current verision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). But the DSM is a socially-constructed diagnostic guide that is in the process of completely revamping the section dedicated to the diagnosis of addiction. Turns out we got it wrong for the past couple of decades! In my opinion, debates about whether people can be “addicted” to be specific objects (porn, food, internet, cell phone use) get us nowhere. For years therapists have treated patients with significant problems related to all these things, which usually come in packages of behavior. Our focus should be on understanding addiction as a relationship problem, not an object-specific problem.
• How should we understand Tiger’s behavior? If addiction is about relationships, then we see that his pursuit of women  has been about something other than just sex. Any therapist in the country who has spent time dedicated to the topic of sex addiction (Patrick Carnes, Jennifer Schneider, Robert Weiss) will say that sex addiction is not about sex. It is about intimacy and emotional connection, or the lack thereof. As humans we are wired for relationships, but adverse childhood events (and trauma throughout life) lead to the avoidance of emotional experiences necessary for healthy emotional development. The result is a person like Tiger becomes an adult doing his best to negotiate the complexities of adult relationships with the emotional/relationship/intimacy skills of a child. No wonder he looks like a deer caught in headlights at news conferences.
• As a person neglects their internal emotional world, very often the emotional energy (which has to go somewhere) gets displaced into academic mental activities or sports. It is not coincidental that many who suffer from addiction and untreated trauma are professional athletes or have professional careers requiring brain power and academic credentials.  A number of news commentators have pointed out that when Tiger came on the pro scene at age 19 his life never was the same. I would add that prior to the age of 19 his life was very different from other kids, how else was he able to go pro at 19? I am not an expert on Tiger Woods and have no knowledge of the events in Tiger’s early life that influenced his present behavior. And in truth, I don’t care, they are not my business. Each person’s past is their own.
• We need to realize that we (even those who work in the media and are taking shots at him) are not so different from Tiger. On some level, we all struggle with past traumas, maintaining intimate relationships, sex, and developmental constrictions. And at times we all have engaged in excessive behaviors that help us disconnect from the world and our emotional pain (like even watching a bit too much professional sports). Sure, we may not have millions in the bank, be the world’s greatest golfer, or have the ability to act out in the ways he has, but just like Tiger, we all have our own life challenges. The real question is whether we are deepening our awareness of our shadow side, and doing the work necessary to own it, integrate it, and evolve our own mental/emotional health.

One final thing. Understanding why Tiger did what he did is very different then letting him off the hook. Let me be clear, I am not attempting to justify his behavior or say his acting out was not his fault. He needs to take responsibility for what he has done, and realize how his actions have hurt a lot of people. But we in society are so quick to judge others, and in a sick way relish watching those on top take big plunges. Instead of buying into the soundbite entertainment value of Tiger’s pain, we could benefit a lot more by exploring how his fall is a mirror for aspects of our own life.

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.

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.