Frequently Asked Questions
1. I am currently struggling with addictive behavior, what do you recommend?
Read: Top five things you should know about addiction, then explore the other links on this website. Unfortunately, there is no one formula that will work for everyone, and the most effective approach for dealing with addiction is the one you craft for yourself based on your own needs/desires. If after reading and studying the material on this site you still are not sure what to do next, then email us.
2. How do you help someone you care about who is struggling with addiction?
Read: How to help someone struggling with addiction
3. What do you think about 12-step programs like AA, NA, CA, GA, and SA?
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). 12-step meetings on the positive side: 1) provide an alternative to acting out in an addiction, 2) provide numerous tools on how to change behavior, 3) reduce shame because people realize they are not alone in their problems, 4) provide a social network more positive than a network of people still engaged in addictive behavior, and 5) for the most part are free. On the con side, 12-step meetings: 1) can become a person’s life to an extent that they remain developmentally constricted and never branch into other areas of life, 2) 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), 3) may overly focus on one object of addiction to an extent that other objects are ignored, and 4) are grounded in a broad spiritual framework that may turn some people off.
4. What do think about self-help groups like SMART and Rational Recovery?
Basically, the same as my previous answer for 12-step programs. But, for those who are turned off by a spiritual approach to intervention, these programs are likely a better fit.
5. How effective are residential (inpatient) treatment programs?
They can be life-saving, a complete waste of time and money, or fall somewhere in-between these extremes. In general, people utilize residential treatment when outpatient care is not working. But one of my strongest complaints of these programs is that they very often admit people into treatment immediately following detoxification (unless they do this step themselves which many 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 (e.g., groups, individual therapy sessions). 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 just about the time a person is being discharged from residential treatment is about the time their brain is actually ready to start engaging in the process! Further, many of these programs charge exorbitant rates for treatment, some $1000 to $1500 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. $50,000 can go a long ways to developing incredible long-term outpatient programs that for that money will pay for services for many years. Or it can pay for one treatment episode lasting a month or two, with the chance of relapse occurring sometime within one year following discharge well over 60 percent.
6. When someone goes to treatment and then relapses soon thereafter, how can you say treatment works?
Read: Long-term solutions
7. What do think about people with 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.
8. What is the best way to stop smoking?
Read: How to stop smoking
9. What do you think about Rapid Opiate Detoxification (ROD) programs?
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, they are no magic pills and I would stay away from such programs.
10. 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: 1) stop use before it starts through prevention efforts, 2) heal drug abusers by getting treatment resources where they are needed, and 3) 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 then should our policy be? 1) 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, 2) beef-up our prevention efforts in families and communities using empirically validated risk/protective factor approaches that address a wide range of adolescent problem behaviors, 3) increase funding for treatment, 4) 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), and 5) decriminalize marijuana for personal use (see Reefer Madness).
11. What do you think about the “Stages of Change” part of the transtheoretical model (i.e., Prochaska & DiCliemente)?
The “Stages of Change” model is one component of the larger Transtheoretical Model of Change proposed 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: 1) arbitrary dividing lines between stages, 2) model assumes people make coherent and stable plans involving change – which often does not happen, 3) research shows many people do not go through the stages as proposed, but skip over stages (i.e., go from precontemplation to action), 4) predictions based on the model are not overly accurate or flat wrong, and 5) 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.
12. I have heard a person has to “hit bottom” before they will really 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, and a good place to start is understanding a bit about motivational interviewing.
13. 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.
It is also important to understand that what becomes an EBP is largely based on what gets researched – and well over 90 percent of all addiction research in the U.S. is funded by the government. As a result, those who hand-out money to researchers are in a position of dictating what gets studied. Recently (2006), Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It was published by the Guilford Press. In the first chapter, the authors say: “What if we were to set aside all current specialist systems, brand-name treatments, and existing programs, and start from the scientific knowledge base to develop social strategies for combating these problems? Those questions lie at the heart of this book.” If one were to really start with the scientific knowledge base, then it would be clear that the title of the book should be called Rethinking Addiction (or excessive behavior) and the content should address all the objects of addictive behavior and not just substances. When I contacted one of the editors of the book to ask why they chose to focus only on substances, I was told that the grant that supported the work behind the book dictated that they had to focus only on substance abuse. This person quickly said that the ideas in the book should generalize to other addictions, but here is a good example of how politics influences research – and ultimately what becomes an evidence based practice. Further, it is important to realize that just because a clinical intervention has no research evidence (per se) behind it does not mean that it doesn’t work. Many clinical interventions have not been studied. In the end, we need to keep a balanced perspective on EBPs and understand their strengths and limitations.
14. How do I find a good therapist?
Read: Finding a good therapist
15. What do think is the optimal intervention for someone who continues to drink and drive despite multiple treatment episodes and legal consequences?
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). The long-term solution to this problem is no different than the long-term solution for anyone who struggles with addiction – they must have a broad addiction management program in place for the rest of their life. 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), car interlock device, license suspensions, exercise program, and volunteer work (particularly if it relates to the consequences of drinking and driving). 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 also stay actively enrolled in some form of expert treatment. It should become a legal condition to maintain a license because research shows that while someone is in treatment chances of drinking and driving (or any addictive behavior) are significantly reduced. One final point: much of the way we handle this problem is through legal sanctions (fines, jail) and ineffective treatment (See: case study of Michelle under evaluation & assessment) that very often leave a person going through the system resentful, demoralized, uninspired to help themselves, and treatment resistant from the beginning. Just as the addiction treatment system needs significant changes, so too does our intervention system on how to deal with the serious problem of drinking and driving in society. If treatment is to be a condition of having a license, then it needs to be effective treatment.
16. What is pseudoaddiction?
Read: Pseudoaddiction versus addiction in a pain population (great Master’s Thesis by my friend Ann Kline)