- How to help someone struggling with addiction?
- How effective are Residential (inpatient) Treatment Programs?
- Do people have to “Hit Bottom” before they can change?
- Optimal intervention for someone with multiple DUII’s?
- Do 12 step programs work?
- What is the best way to stop smoking?
- What do you think about “evidence-based practices”?
- Do people have addictive personalities?
- What about SMART and Rational Recovery groups?
- Do Rapid Opiate Detoxification (ROD) programs work?
- What do you think about the “war on drugs”?
- What is the “Stages of Change” model?
1) How to help someone struggling with addiction?
Being in a relationship with someone who struggles with addiction can be agonizing. It is hard to see (and experience) those we care about hurt themselves. The natural reaction for most is to want to help, but unfortunately, few people really understand how best to help.
It is true that treatment can help, but studies have also shown that when a person enters treatment with low motivation to change, they very often don’t engage in the process, frequently drop out early, and usually resume their addictive behavior shortly after discharge.
As a result, it does not take more than a couple of failed treatment episodes before we begin to lose hope that things will change, get more and more angry at the person struggling with addiction, and become resentful of all the time and effort that we have put into attempting to help them.
2) How effective are Residential (inpatient) Treatment Programs?
One of my strongest complaints of with residential treatment programs is that they often admit people immediately following detoxification (unless they do this step themselves which many treatment programs do).
There is now very strong evidence that once a person is detoxed from alcohol or drugs, their brain needs at least a month – and ideally two months - before it is ready to truly engage in the treatment process. During this time, neuroimaging studies have shown the brain regains significant cognitive and memory function necessary for treatment success.
Unfortunately, most residential programs do not take this research into consideration, and the time your brain is actually ready to start engaging in the process is typically when you are discharged from the program! Further, many of these programs charge exorbitant rates for treatment, ranging from $1,000 to $1,500 per day.
When people are led to believe that residential treatment is the only answer, and they mortgage the house to pay for care, I begin to get very uncomfortable with this intervention option.
Investing $50,000 in treatment can go a long ways to developing incredible long-term outpatient programs. Or that $50,000 can pay for one treatment episode lasting a month or two, with a 60% chance of relapse during the first year following discharge.
People need long term solutions to addiction.
3) Do people have to “Hit Bottom” before they can change?
This is a myth perpetuated most commonly by self-help programs. The idea that a person will only find motivation to change addictive behavior when consequences are severe enough is not based on research. It is often used as an explanation when those attempting to change behavior using the principles of self-help programs continue to struggle.
No one should be told they must hit bottom (it is only knowable in retrospect). Instead, we must understand what really drives change.
4) What is the optimal intervention for someone with multiple DUII’s?
The fact that many people continue to drink and drive after repeat treatment episodes is not surprising since most people continue to struggle with addiction to some degree once they leave treatment (i.e., it is a chronic relapsing condition).
Just like an asthmatic or hypertensive patient likely requires medication for life, the person who has a history of drinking and driving requires constant intervention that can come in many forms:
- Expert treatment
- Use of medication (e.g., Vivitrol, Campral)
- Implement a car interlock device
- License suspensions
- Exercise program
- Volunteer work
Because of the enormous consequences that result from the problem of drinking and driving, if a person cannot deal with this problem on their own successfully – meaning after one or at the most two DUIIs (and even this may be lenient if after one DUII a person clearly has a history of dependent drinking), then they should not be allowed to have a license to drive a motor vehicle unless they stay actively enrolled in some form of expert treatment.
More information on intervention for multiple DUII’s.
5) Do 12 step programs work?
This is a loaded topic, but my general answer is that that 12-step programs can be incredibly helpful for those struggling with addiction. Research indicates that for self-help meetings to work, a person must attend at least once weekly, and engage in the process (i.e., participate in
the meetings and self-help recovery activities).
Pros of 12-step meetings:
- They provide an alternative to acting out in an addiction
- Offer numerous tools on how to change behavior
- Reduce shame because people realize they are not alone in their problems
- Provide a social network more positive than a network of people still engaged in addictive behavior
- For the most part are free
Cons of 12-step meetings:
- Can become a person’s life to an extent that they remain developmentally constricted and never branch into other areas of life
- May perpetuate myths about change (i.e., all medications are addictive, so to be truly abstinent don’t take anything – and you have to hit bottom before you can get well)
- May overly focus on one object of addiction to an extent that other objects are ignored
6) What is the best way to stop smoking?
The first step in helping a smoker is to explore their motivation for change (or lack thereof), and help them increase it in the direction of wanting to stop. Often motivation can be increased when people realize the benefits of quitting, including:
- Food tastes better
- Get sick less
- Chance of living longer
- Increased energy
- Breathe easier
- Lower risk for heart attack, stroke, and cancer
I have developed 5 Actions to apply as a process for people to resolve any addiction, including smoking.
- Stay away from smokers and avoid alcohol
- Maintain a healthy diet and exercise regularly
- Take one of the five FDA approved medications to help quit smoking
Read more on how to stop smoking.
7) What do you think about “evidence-based practices”?
The recent movement for healthcare providers (including addiction treatment programs) to implement evidence-based practices (EBPs) is to produce greater benefits to consumers and society that seek out help for a variety of ailments, including addiction. There is no question that bridging the gap between science and practice will result in improved care for many people.
Much of this website is dedicated to understanding the science behind what works to successfully intervene on addiction. But like most things, it is important to understand that even EBPs can be problematic.
Dean Fixen, the renowned expert on research related to the implementation of EBPs, has pointed out that in the U.S. the federal government spends over $95 billion a year on research to develop new treatments, 1.8 trillion a year on supports for services to people, and less than $1 billion a year on how to implement new evidence-based interventions into practice.
In the addiction treatment industry, there is significant evidence that despite many great EBPs, many programs have failed to implement them into their programs. Bottom line, we are in the infancy of really understanding how best to take EBPs and implement them in the real world.
Read more on evidence based practice.
8) Do people have addictive personalities?
Research has shown that there is no such thing as an addictive personality, because addiction is found across all major personality classification systems (e.g., Five Factor Model). Many people say they have an “addictive personality”, but what they are really saying is that there is a significant part of their life that engages in excessive behavior across many objects of addiction.
Where personality does play a role, is that different personality types appear to moderate and mediate (in statistical terms) different paths of addiction. Bottom line, you don’t have an addictive personality.
9) What do you think about self-help groups like SMART and Rational Recovery?
Essentially, my thoughts on these programs is similar to my response to 12 Step programs. But, for those who are turned off by a spiritual approach to intervention, these programs are likely a better fit.
10) Do Rapid Opiate Detoxification (ROD) programs work?
Such programs are expensive, do nothing to address addiction, and are often marketed by organizations in less than honest ways about their real usefulness. In sum, there are no magic pills and I would stay away from such programs.
11) What do you think about the “war on drugs”?
The modern war on drugs really began when the Office of National Drug Control Policy (ONDCP) was created in 1988 to deal with the epidemic of cocaine abuse throughout the 1980s. Since its inception, ONDCP has spent billions to battle illegal drug abuse in the United States, primarily pushing three goals:
- Stop use before it starts through prevention efforts
- Heal drug abusers by getting treatment resources where they are needed
- Disrupt the markets for illegal drugs by attacking the economic basis of the drug trade
In a critical analysis of the effectiveness of ONDCP, Dr. Matthew Robinson and Dr. Renee Scherlen, both Associate Professors from Appalachian State University, conclude that the drug war has been a massive failure.
After reviewing six editions of the annual National Drug Control Strategy between 2000 and 2005, they provide significant empirical evidence that ONDCP has not represented the facts about the drug war accurately, often skew statistics to put a rosy face on less than productive results, and in the end, should be abolished.
What should our policy be?
- Stop saying “war on drugs” as this punitive ideological language does not represent a well thought-out and humane approach to addiction in our society.
- Beef-up our prevention efforts in families and communities using empirically validated risk and protective factor approaches that address a wide range of adolescent problem behaviors.
- Increase funding for treatment.
- Drop the “abstinence” approach to drug abuse as the only viable intervention option and incorporate scientifically validated harm reduction approaches (e.g., needle exchange programs).
- Decriminalize marijuana for personal use (see Reefer Madness).
12) What is the “Stages of Change” model?
The “Stages of Change” model is one component of the larger Transtheoretical Model of Change by Prochaska, DiClemente, and Norcross. It was first introduced into the addiction field in the early 1980s, and has since become so popular that many treatment programs are using the model as a way of organizing treatment interventions.
Although the model has great intuitive appeal, recent research has shown their are many problems with the model and that it should be abandoned.
The problems include:
- Arbitrary dividing lines between stages.
- Model assumes people make coherent and stable plans involving change (which often does not happen).
- Research shows many people do not go through the stages as proposed, but skip over stages (i.e., go from precontemplation to action).
- Predictions based on the model are not overly accurate or flat wrong.
- It does not capture the dynamic complexity seen in behavior change.
Despite the research and these reasons, clinicians continue to use the model and believe it to be a scientifically valid way to think about behavior change. If you really want to educate yourself about this model, check out the following references:
- Sutton, S. (2001). Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction, 96(1): 175-186.
- Littell, J.H. and H. Girvin (2002). Stages of change: A critique. Behavior Modification 26(2): 223-273.
- Whitelaw, S., S. Baldwin et al. (2000). The status of evidence and outcomes in the Stages of Change research. Health Educ Res 15(6): 707-718.
- West, R. (2005). Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036-1039.
In summary, the Stages of Change is a nice idea, but current evidence does not support it as a valid way to think about behavior change. On the upside, we should not abandon the entire Transtheoretical Model and instead focus more on understanding the processes of change for which there is much more empirical support.
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