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.

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

This past week I had a few minutes to spare in Washington DC, so I dropped by the National Geographic Society headquarters and discovered a project that has significant relevance to successfully solving the problem of addiction. Writer and photographer Dan Buettner embarked on a journey around the globe in search of communities that optimized lifestyle for longevity and happiness, places he calls blue zones.  He boiled down his research for the book Blue Zones into principles for living a long and prosperous life. Here is a great summary of the book he did for TED:

For those who struggle with addiction, the keys outlined in the book (and the speech above) provide a road map for translating the MRC solution into reality. Let’s look at how they line up:

Manage
Successfully dealing with addiction requires identifying those things in your life that are chronic issues, and then developing strategies that appropriately keep these things in-check. When we expect to permanently solve a chronic problem we set ourselves up for failure because there is no cure or end to these issues, they require ongoing attention. Addiction, diet, chronic medical issues, time and exercise are all things we must learn to successfully manage. In Blue Zones, the keys that line up with manage include:

• Learn to move naturally. Those who live to be 100 rarely engage in rigorous exercise. Instead, they incorporate  walking, gardening, yoga and other less body-stressful movements into their daily routine. Developing a healthy lifestyle free from addiction necessitates learning to move in the world in a new way, in a natural, physically and emotionally pain-free way.
• Slow down. Our culture perpetuates addictive behavior by encouraging lifestyles where multi-tasking, reliance on technology, and instant gratification become packaged in a speedaholic existence. Not so for those who live in blue zones. An important aspect of successful long-term management of addiction is learning to slow down, become conscious of how you spend your time, and align it with what is most important in your life.
• Eat and drink wisely. Food and drink are common objects of addiction, and although abstinence from alcohol is possible, we cannot stop our relationship with food. The same goes for those who struggle with sexual addiction. It is not possible to remain abstinent from sex, we are sexual beings by nature and healing requires finding healthy ways to express our sexuality. The key is moderation, balance, and of course, eating more fruits and vegetables. Red wine has also been shown to increase longevity, but if it creates more problems than benefits (e.g., abuse, relapse) it should not be on your list.

Resolve
There are some life problems that we should not manage, but solve, permanently. Homelessness, debt, acute pain, many developmental constrictions/deficits, legal problems, and suicide ideation. None of these things are healthy to manage over a long period of time, and our work should focus on resolution. Two significant problems most addicts need to resolve are lonliness and isolation. The key that lines-up with resolve is:

• Be Connected to Others. Those who live the longest put family and loved ones first. They belong to communities that nurture and protect each other. Many share their spiritual faith in community, and hang out with people that have healthy habits, both physical and emotional. I have written a lot about how the essence of solving the problem of addiction is disconnecting from object-relationships and learning to engage in healthy, intimate connections with people. But to do this very often requires resolving barriers to human relationships. These barriers include unresolved trauma that lead to isolation, developmental stuck points, and debilitating shame and grief. This work is not easy, but necessary for relationships to blossom.

Create
Many who struggle with addiction spend all their time on the pathological side of the equation. Treatments, interventions, fixes, cures, treatments….all intended to reduce or stop addictive behavior. This stuff is important, but at the same time it needs to be integrated with actions that optimize life.  Sometimes taking a break from intervening on addictive behavior and directing energy to what we want out of life can actually produce the outcomes we seek. Those who live in blue zones:

• Have a clear purpose. They call it “ikigai” – the reason for which you wake-up in the morning. If your ikigai is that you don’t want to drink, smoke,  or act-out today, well…this is not a very compelling reason to get out of bed, it just gets you to focus on what you don’t want! The key is redirecting your life energy towards creating what you do want.

For additional information on blue zones, checkout the author’s website: bluezones and the book.