I understand why Beautiful Boy is a #1 New York Times bestseller. It’s a very moving and insightful account of one father’s journey through his son’s addiction, a journey millions of parents have made. David (the author) does not hold back. His writing is powerful, emotional, lucid, and honest. He loves his son Nic to the ends of the earth, there is no doubt about that. Nic is more than just a beautiful boy, he is everything to David. And why wouldn’t he be, he is his son, even when high on methamphetamine and other drugs. At times I laughed, other times I cried. I did not want to be reminded that as a parent there are limits to my ability to protect my son. But it is one of the gifts of the book.

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 comment from a previous post suggested I watch a documentary titled “Cracked Not Broken” by independent film maker Paul Perrier. It was time well spent. In short, the film is about a woman named Lisa who is addicted to cocaine and works as a prostitute to support her habit. Much of the film is an interview with Lisa in a hotel room, where she honestly and openly talks about various aspects of her life on the edge – or as she calls it “the game.” I love how the film goes from black and white to color as she feels the effects of the cocaine she has just injected into her body (yes, there are some graphic scenes). It also shows that despite a number of treatment espisodes, Lisa continues to struggle with relapse hitting home how we understand addiction today – a chronic, relapsing brain disease.

What does Lisa need to successfully move forward in her life?

• Healthy intimate relationships. Cocaine and sex have become more important than relationships – more important than her daughter, her friends, her family. Ultimately, for her to heal, she needs deep emotional connections to those she loves and cares about. For her to have sustained, healthy emotionally-fulfilling relationships, will require that treatment and intervention place increased emphasis on helping her understand her emotional world in a safe way, and developmentally addressing her emotional deficits and constrictions .
• Trauma resolution.  Just watching Lisa in the video you can sense the chaos and trauma in her life. The splitting off and not letting herself feel is classic trauma. I have blogged about trauma being the gift that keeps on giving (although it is hardly a gift), and for Lisa to move beyond her addiction will require significant trauma work. Again, this is where traditional drug treatment programs often fail clients. They may diagnose PTSD, but rarely have the resources, time, or expertise to address it sufficiently. For someone like Lisa, this work likely will require many months (or years), but usually never happens because of short treatment stays. 
• Medication. Addiction is a brain disease, and as Eric Nestler (Professor and Chair of Neuroscience at Mt. Sinai) has so aptly put it – one that hijacks the brain with a force almost unheard of in our natural world. As a result, for Lisa to succeed, she will likely need some medication to help her with cravings, depression, anxiety, and other symptoms associated with her long use of cocaine as she slowly engages into a life without drugs and sex. The HBO series on addiction has an excellent segment on relapse from Anna Rose Childress where she explains why the brain is so vulnerable to relapse. Her example in the film is a guy who is addicted to cocaine and reminds me a lot of Lisa. Dr. Childress even talks about an experimental medication for cocaine abusers that dramatically reduces the brain activity associated with craving (baclofen). Lisa would also likely benefit from medications that reduce some of the hypersensitivities around her trauma, allowing the critical therapuetic work to progress more rapidly.
• Creativty. Actually, her willingness to be interviewed for the film, and share her story with others, taps into her creative side. She wants something “good to come from [her] addiction” and long-term success will necessitate that she continue to find ways to make meaning from her prior life experiences. Writing, singing, becoming a counselor, working with youth, helping other woman get off the street – these things become catalysts for turning shame into meaning.

As an afterword, there is a website dedicated to the film where Lisa had a blog – one that ended on 10/20/08 with her having been through treatment and acheiving over a year of abstinence. She said she is going back to school to become a social worker. Since the blog entry, I can find no updates on how she is doing. My hope is that she has connected with a  long-term solution that leads her permanently away from addiction. Godspeed Lisa.

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.

One of my first and most memorable patients was a Native American man who I was treating for alcohol dependence (among many other complicating factors). On multiple occassions, he had been admitted to the hospital for detox with blood alcohol levels that would kill most humans. He could drink a lot, but the problem was he also had a traumatic brain injury that required medication, so with every relapse came the potential for death and need for hospitalization. After months of weekly individuals sessions, and despite frequent relapses, we had an incredibly strong therapuetic relationship – so strong that one day he came in to session and said…

Your approach isn’t working. I know you mean well, but the western way is hard for me to understand. Here is my bible…and he handed me a copy of Seven Arrows by Hyemeychsts Storm. It was one of those valuable early lessons  where I realized that there is no one right path in healing from addiction. Only the path that is right for you. But the story continues…

Months later after reworking our treatment plan around the medicine wheel, he is still relapsing, ending-up in the hosptial for detox, and I am left wondering where I went wrong. Fortunately, my Clinical Supervisor at the time was an insightful, experienced therapist who suggested I review all hospital detox admission records since he first entered treatment to gain some perspective on what was actually happening. Since every relapse had been followed by a hospital admission, I was able to easily complile a graph of relapses over time, and when I did, something amazing materialized.

He was getting better. It was right there in the data. After plotting the relapses on a graph I was able to see that the time between them was increasing – actually doubling with every relapse. What on the surface seemed like failure to me, was in fact – after reviewing the data – success. And why should have I expected progress to be any faster? This guy had years and years of drinking history behind him. Change is a process, and with addiction, takes incredible patience. We also know that addiction is a chronic, relapsing medical condition where relapse is part of the process. When I presented the graph to him at our next session he was equally pleased, and even more motivated to continue the progress.

Six years into our work he had well over two years of sobriety. His relapses continued to decrease in frequency maintaining the pattern he began when he entered treatment. The moral of the story: 1) follow a recovery path that is right for you, 2) track relapses and other significant events because data can provide insight where memory fails, 3) change is slow - patience is key, and 4) relapse, even after significant abstinence time, should be an opportunity for learning and not a time for shame and blame. We all make agreements with ourselves to do things (diet, exercise, New Years resolutions), and we all fail at times. Relapse is not an addiction phenomenon, it is a human phenomenon.

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

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

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

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

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

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

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.

When working with those who wish to change addictive behavior I am often struck by how many issues require attention after conducting an evaluation. Not only do most struggle with multiple addictions, but there are often mental health, legal, financial, social, housing, and employment issues to grapple with as well. Combined, these problems can easily seem overwhelming, particularly if you are of a mindset that every issue needs some specific intervention.

Here is where systems thinking plays a key role in successful treatment and long term management. In short, systems thinking helps us to understand that addictive behavior is an outcome of a complex system of interacting issues, for example:

In this diagram, mutliple mental health, addiction, physical and environmental problems combine to create many problems for this individual. In treatment, we identified the different issues, and then spent time drawing arrows between them and talking about how they all relate. We then uncovered a key leverage point for change that in all prior treatment episodes had been missed – an undiagnosed sleep apnea. Turns out it is hard to make progress on much in life if you are constantly in a daze. After a night at the sleep disorders lab and a confirmed diagnosis, we started  treating the sleep problem and within days were making progress on the other issues.

Of all the problems listed for this patient, would you have thought the key to making significant progress was a sleep issue? The most powerful leverage points are most often not obvious.

I wrote a paper about this topic some time ago, but thought I would post a more parsimonnious version of the top ten reasons treatment fails patients. The point is not to suggest that treatment is always ineffective, just that we have a long way to go to optimizing it for those who struggle.

• Treatment focuses on select objects of addiction and does not address the entire package of addictive behavior (see previous post).
• Treatment time is way too short – often lasting days or a few months, instead of years like other chronic medical conditions.
• Treatment relies heavily on group therapy, an abstinence-based approach, and use of 12-step principles instead of indivdiualizing treatment to patients needs and using a wide range of evidence-based practices.
• Underlying mental health, trauma,  and developmental deficitis/constrictions go unaddressed or undertreated.
• Use of medications specifically approved by the FDA to treat addictions, including naltrexone, acamprosate, buprenorphine, and methadone, are underutilized in treatment.
• Treatment overly focuses on the pathological side of the equation, and does not encourage interventions based on positive psychology and creativity.
• Treatment programs forget they are running a business, and that patients really are customers, even when they are mandated to treatment. What would treatment be like if funding was based on outcomes specific to customer satisfaction?
• Too much emphasis is placed on stage models of treatment when there is a much stronger base of evidence for universal processes of change.
• Treatment programs see less than 10 percent of those in need of help. How can programs better align themselves with the needs of thier community and broaden the use of their resources to help a greater number of people (i.e., population-based medicine).
• Treatment often remains disconnected from other important healthcare and community stakeholders. Disconnects between crimminal justice, primary care medicine, policy makers, and others mean many people fall through the cracks and ultimately fail treatment.

Perhaps you can add a few to the list?