A few months ago, I ventured into the world of video, posting some clips from a presentation I did about addiction and treatment. The initial clips were focused on understanding addiction, and since then, I have been meaning to get back to the lecture and do the same for treatment. Recently, I did go back and review the lecture and realized that I can speak much more clearly about the nature of addiction than I can about how to deal with it as a problem. I think this is because there is not one way to help someone with addiction. We have multiple treatments, methods, medicines, and programs that can all contribute to good outcomes. At the same time, I believe the number of choices also can become paralyzing and unhelpful when all that someone really wants is to be given clear direction on what to do. Sometimes 12 steps, 7 habits, and even 5 actions can be overwhelming. Enough said. I did find a couple of clips that pertain to treatment, but they don’t discuss the overarching 5 Actions framework that I am now evolving as a way to think about intervention. But soon. Check these out and let me know your thoughts.

I recently talked with a Huffington Post reporter about the Real Tab for Rehab: Inside the Addiction Treatment Biz. In our discussion, I pointed out that to a large extent we still have an addiction treatment system that provides short-term (acute) treatment for a long-term (chronic) problem (this key point did not make the article). In addition, the current system treats less than 10 percent of those who could benefit from some kind of intervention at a cost that will likely reach $34 billion by 2014, more than double the spending from 2005. In my opinion, a lot of money is being spent on helping a minority of those who struggle with addiction, and sadly being spent on expensive residential treatment stays that research indicates is not more effective than less expensive outpatient care. Bottom line, the billions being spent could be invested in those who struggle far more wisely.

Not too many years ago I was attending an addiction conference where a number of  treatment centers were advertising their services. I struck up a conversation with one of the marketing reps of a well-known residential program. She explained to me that because of the escalating cost of treatment, her team had developed a program that was only ten days in length, thus reducing the total treatment cost to about 15K while maintaining the effectiveness of a longer residential stay. As I always do in these situations, I asked her about proof that the program worked. She had a well-rehearsed answer, but like most treatment programs, no reliable and valid measures had been employed to measure outcomes. Even if some had been used, we know that 10 days hardly scratches the surface of what needs to happen to help someone with addiction.

Am I opposed to residential programs? Not at all. At times I believe these programs are life-savers and provide a strong foundation upon which to build a solid outpatient management plan. Many employ very skilled, compassionate, and hard-working counselors that know how to help patients stuck in addiction. Some charge reasonable rates for their services and avoid the “spa-like” add-ons that contribute nothing to long-term outcomes. What I am opposed to is marketing that feeds on the vulnerabilities of the populations that seek out their help. Many parents will go to the ends of the earth to help their addicted child and not think twice about mortgaging their home and draining their savings if someone tells them their program will save their kid. Even for those with money, the idea that one can “buy good outcomes” if just the right program is utilized is simply not true.

What can you do? You can spend your time understanding the nature of addiction, what science has to say about treatment interventions, and then spend your money wisely on what will result in the best possible long-term outcomes. What are some of the best financial investments in treatment? This slide from a recent presentation provides you a quick reference point for understanding how a number of treatment interventions rank in terms of scientific evidence. Notice that brief interventions, addiction medications (Campral, Revia), the Community Reinforcement Approach (CRA) and motivational enhancement interventions all rank very high in terms of evidence. Also notice what ranks far down the list: residential treatment, Alcoholics Anonymous (AA) and 12-step facilitation therapies, and general counseling. Note that it is not that these things cannot be useful in overcoming addiction, they can be very helpful. But when you compare their effectiveness through the lens of science to other options, and take into consideration the cost of each, it is clear we could be spending the billions of treatment dollars far more wisely.

The goal is to maximize the best possible intervention outcomes over many years (and for some a lifetime), not a few weeks or months. To do this, we need to employ the best interventions at the lowest cost. Combining free community resources, outpatient therapists, medications, self-help groups, and motivational incentives will give you the biggest bang for your buck.

As I laid in bed thinking about the next day, about my turn, fear flooded my entire body. I was like a pressure cooker with no relief valve, and I knew I had to do something fast. I dressed quickly and left my room, walking outside into the cold Arizona night. The black sky was speckled with a million shining stars lighting up the desert floor, casting shadows on giant, prickly cactuses. I walked quickly along the side of the road, exhaling fear with every breath. I began to feel better, more grounded and intent on making it into town. Every few minutes I would squint as a car’s oncoming headlights blinded me, but I never missed a step. After some time, I felt a sharp pain in my side. Then my left calf began to tense up and I wondered how far I had walked. I wondered even more about how far I had left to go, whether walking alone in the middle of the night on a dark road was such a good idea, and whether I would survive confronting my fears in an experiential therapy group the next morning.

My week-long experience in Tucson was only one of a number of therapeutic journeys I have taken during the past two decades. At the time I took my long walk in the Tucson desert I understood very little about how professional therapy ultimately translates into a better life. I was there because that is what I thought I was supposed to do to get better. It was a challenging experience, like many of the therapeutic journeys I have been on, because the essence of the therapeutic work was emotional. Since I had lived much of my life in my head, learning to connect with my body and feelings was not natural, particularly when I felt I had so little control over these things. Although I can honestly say it was not the most enjoyable week, after it was over I felt more complete, more integrated, more able to be in the world in a broader context. Some of the emotional pressure had been released safely, and I felt more alive. Such outcomes have always been the reason I keep going back for more, even to this day.

What I now realize after years of personal therapeutic work, counseling patients, and studying the research on treatment outcomes, is that good therapy advances developmental capacities that make healthy relationships possible. In addition, by expanding developmental skills, it becomes possible to optimize overall mental and emotional functioning, leading to an expansion of life opportunities, a better alignment between innate talents and employment, and a more meaningful life. What I have also realized is that advancing developmental capacities does not necessarily require professional treatment, but can result from a number of life experiences.

Although medications and various cognitive-behavioral therapies so often used in addiction treatment play an important role in solving the problem of addiction, they fall short of a permanent solution because they are not intended to progress emotional development. When I reflect back on the many therapists I have worked with, self-help groups I have attended, experiential programs I have endured, and the wide range of therapeutic approaches I have subjected myself to, it is clear now that the most important ingredient in all of them was people, not specific therapies, medications, or programs. Treatment works best when in the context of relationships, the skills necessary to initiate, develop, and maintain healthy relationships – skills underdeveloped because of time spent with objects – are nurtured.

The good news is that anyone, at any stage of life, no matter how badly addicted to objects, can evolve their developmental capacities and engage in life in a deeper and more meaningful way.

For the past few years I have taught a foundations course on addiction treatment to graduate students. An important aspect of the course is helping students understand that longterm successful outcomes  necessitate resolving underlying drivers of addictive behavior, namely, adverse childhood experiences. In an effort to illustrate concretely how this may be done, I enlisted the help of a good friend and colleague, Mark Girard, who is a master at knowing how to help people heal from deep, traumatic wounds. As a Licensed Clinical Social Worker and certified Jungian Analyst with years of experience, he is incredibly skilled at working with a wide range of altered states, or emotional constrictions due to trauma. What impresses me most about Mark is how he uses himself as a tool in therapy. He walks his talk and maintains a presence with patients that is the essence of what a good therapeutic relationship is all about. During his recent visit to my class he agreed to have me videotape his lecture. The approximate 35 minute presentation is a gift to us all. I encourage you to take the time – quiet, focused time – to sit and hear what he has to say.

In the presentation, Mark mentions an article by Dr. Bruce Perry from the ChildTrauma Academy that was required reading in class. The article is titled Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized children and is a nice adjunct to his lecture. He also makes reference to Babette Rothschild’s wonderful book on trauma, The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment, and the classic article on trauma by Bessel van der Kolk, The Body Keeps Score – both among the very best reads on the topic of trauma.

I have mentioned Dr. Robert Thayer before on this site, but have not dedicated a blog entry to his ideas until now. When I first read his book, Calm Energy: How People Regulate Mood with Food and Exercise, I was immediately impressed by the implications of his  work for those struggling with addiction. In a nutshell, he provides a very strong case that many of our moods and unhealthy eating habits have in common two biopsychological dimensions that he calls energy and tension. In an earlier book (The Origin of Everyday Moods, 1996) he describes how the dimensions can be used to create the illustration below.

The above four states represent different expressions of our energy and level of stress. Calm Energy is the quadrant where we find our best moods. We have energy and no tension. It is similar to the states people call flow or being in the zone. It is a place we want to be, where our attention is focused, we are productive, and we feel good about life. It is not a place where addiction is found, and in fact, is really the antidote to cravings and addictive appetites. The opposite of Calm Energy is Tense Tiredness. This unfortunately is the place many of us find ourselves these days, in large part due to the speed of life, decreases in sleep, and increases in stress. It is a place of low energy, bad moods, anxiety and depression. It is also the state where addiction thrives. When we feel tense and tired there is a natural tendency to want move away from this state, and addictive behaviors are among the most powerful, reliable, quick, and easy ways to disconnect from Tense Tiredness. I say disconnect because engaging in addictions does not really provide an antidote to this state. Instead, it may in the short run give us more energy, and change our mood, but only temporarily. When the addictive behavior ceases, chances are good that what follows will be more tension and lack of energy, perpetuating the relapse cycle.

I like to think about Calm Tiredness as a lazy Sunday afternoon. In general, it is a pleasant state, but often not as productive or positive as Calm Energy. Nothing wrong with it, and in fact we need down time to recharge our batteries. The final state, Tense Energy, is a state where we are quite productive and busy, often due to deadlines and being rushed for time. Many Type A personalities fit this state, as well as those who like to live on the edge and seek out thrills.

In my own life I find the model incredibly useful in helping me understand my own eating, exercise, sleep, and mood patterns. One of the best things you can do for yourself is take a day (or two) and track your level of energy and tension by the hour. Rate each on a scale of 1 to 10 and then plot the results on a graph. It is revealing to see just how significantly these states change in the course of an average day. The graph also helps to identify intervention points for: (a) preventing relapse, (b) developing optimal times for exercise, and (c) determining whether we are getting enough sleep. In addition, the graph can help you understand how time of day subtly influences how we think about life problems.

In sum, addiction most often shows up when we are tense and tired, but can also occur in the other states as well. Among the most significant points Dr. Thayer makes in his book is that the single best way to cultivate a life of calm energy is by developing a regular habit of exercise. Perhaps that is why the National Institute of Drug Abuse has already invested over 4 million in research into the connections between addiction and exercise.

“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).

The following interview with Dr. Mate provides additional context for his work and beliefs about addiction. One surprising statement he makes is that less than five percent of his patients overcome their addictions - not the best of outcomes. Of course what “overcome” means and how to define outcomes are messy topics, but I am far more optimistic about  the tenacity of the human spirit to change. Addiction is most definitely a challenge, but one reason for poor outcomes has been the lack of understanding about the nature of addiction, and the need for a comprehensive solution like MRC. Watch the interview, and then let me know your thoughts about Dr. Mate’s conclusions.

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.

Dr. Sandra Bloom is a psychiatrist largely responsible for the creation of the Sanctuary Model, which is both a framework for treating trauma, as well as an organizational change model that integrates evidence-based trauma interventions with the benefits of therapuetic communities. The brillance of this model is that it optimizes the safety and healing of all parties involved in social systems of care: patients and clinicians, prisoners and judges, victims and advocates, addicts and counselors. It is a model, in my opinion, that is applicable across all organizations no matter what their purpose, because it provides a roadmap for how humans should treat one another, no matter what position they may find themselves in.

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