At a training not long ago on CRAFT, the presenter told a story that I want to pass on to you. But first, if you have never heard of CRAFT, it stands for Community Reinforcement and Family Training which is an evidence-based approach that family members (or friends) can use to facilitate getting an unmotivated loved one struggling with addiction into treatment. I am most fond of this approach because, unlike traditional interventions that rely upon coercing a person into treatment through harsh group feedback, CRAFT relies upon using basic behavioral strategies to rearrange the world of the addict so he or she internally reaches the decision that treatment is necessary. We have known for a long time that external motivation gets the job done; interventions do often lead to treatment. But unfortunately, once there, the person we so badly care about does not engage in treatment, does not really want to be there, and often drops out. We are back to square one and saying that treatment does not work. It is a vicious cycle.

In these situations, treatment fails because of a lack of internal motivation. Those who need to change their behavior have to want to change their behavior, which is why CRAFT is so powerful. It works to increase internal motivation for change by eliminating the positive reinforcement for acting out in an addiction, and enhancing positive reinforcement for non-acting out behaviors. If you don’t understand basic behavioral approaches to change using reinforcement, then it is time for my story.

A woman who had been admitted to a psychiatric ward was driving the staff crazy. From the time she woke up until the time she went to bed in the evening she would scream her head off. The staff tried everything they could think of to get her to stop screaming, but nothing worked. She had to be placed in a room alone, away from the other residents, and restrained at times. Although medications could have been used to sedate her (and probably were at times), they were not the answer. After many frustrating weeks of listening to her loud cries, a doctor was brought in to see if he could help. His name was Nathan Azrin.

Nate walked down the hall to the woman’s room as staff likely snickered about how he possibly could make a difference given all that had been tried. When he arrived, the woman was sitting on the edge of the bed rocking back and forth screaming like she did throughout the day. He stood at the doorway for quite some time. He may have thought about why she was screaming, but also knew that whatever the driving reason, she could not speak and exploring the why would likely be a long journey. Instead, being a behavioral psychologist, he considered her behavior and what he wanted her to do instead of screaming. Well, this was easy, he wanted her to stop screaming. Then, he considered the times when she was doing what he wanted her to do: eating, sleeping, and breathing. During these activities she did not scream. As he stood in the doorway, he began to focus more on the immediate moment to moment rhythm of her screaming and breathing. Then he got an idea…

Right at the moment when she stopped screaming to take a breath, he walked over to her and gently stroked her hair. After she inhaled and began screaming again, he slowly moved back to the door and waited until she had to take another breath. He then repeated the movements with every breath: move close to her, look her in the eyes, gently stroke her hair, and then move away as she screamed. Nate knew, that at our core, we all have one unifying need: love. And he believed that by reinforcing the moments when she was not screaming, even though they were just seconds, with loving touch, that just maybe…maybe, he could alter her behavior. While staff had isolated her, restrained her, and stayed clear of her, he moved closer to her. And his approach worked. By that evening, he was sitting next to her on the bed, gently stroking her hair, and the screaming had stopped. He told the staff that when she woke up the next morning and started to scream, someone was to sit next to her and gently comfort her. In fact, anytime she began to scream, the antidote was the same.

I love this story because so often when we are challenged in life we tend to overlook the obvious. We seek out expensive treatments, elaborate self-help strategies, or engage in complex change regiments only to become frustrated when change eludes us. Dr. Azrin is among the most cited psychologists of all time, and although he may go down in history for his popular read, Toilet Training in Less Than a Day, for me, he will go down as an individual who taught me about love.

Last year I dedicated a post to the work of Dr. Bruce Alexander, a psychologist from Canada who wrote a great book about the globalization of addiction. I am now extremely excited that my good friend Jari Chevalier, from Living Hero, recently completed an interview with him that you can access here. There are so many wonderful things in this podcast that I encourage you to take the time to hear what Dr. Alexander has to say about addiction and our society. Just to wet your appetite, here are a few things I found most insightful:

• 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!

As a young boy, I remember venturing out on summer evenings to play hide-and-seek with the other neighborhood kids. We made up teams, sought out secret hiding places, and took full advantage of the local woods that surrounded our corner of the world. Our parents all knew each other, and while we were expending our energy running around in the dark playing games, they were talking around tables and sharing food and drink. There was no internet, cell phones, or other multimedia distractions competing for time. Life was simpler, slower.

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

“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).