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Q & A |
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Note: questions
below are bookmarked (hyperlinked) to answers further on
down
1.
I am currently
struggling with addictive behavior, what do you recommend?
2.
How do you
help someone you care about who is struggling with
addiction?
3.
What do you
think about 12-step programs like AA, NA, CA, GA, and SA?
4.
What do
think about self-help groups like SMART, Rational Recovery,
and SOS?
5.
How
effective are residential treatment programs?
6.
When someone
goes to treatment and then relapses soon thereafter, how can
you
say treatment works?
7.
What do
you think about people with addictive personalities?
8.
What is the
best way to stop smoking?
9.
What do you
think about Rapid Opiate Detoxification (ROD) programs?
10.
What do you
think about the "war on drugs"?
11.
What do you think about the "Stages of Change" (i.e.,
Prochaska & DiClemente)?
12.
I have heard a person has to "hit bottom" before they will
really change?
13.
What do you think about "evidence-based practices"?
14.
How do I find 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?
16. What is pseudoaddiction?
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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.
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2. How do you help someone you care about
who is struggling with addiction?
Read:
How to help someone struggling with addiction
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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.
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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.
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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.
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6. When someone
goes to treatment and then relapses soon thereafter, how can
you say treatment works?
Read:
Long-term solutions
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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.
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8. What is the
best way to stop smoking?
Read:
How to stop smoking
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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 pill and I would stay away from such
programs.
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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).
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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.
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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.
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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.
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14. How do I find a good therapist?
Read:
Finding a good therapist
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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.
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16.
What is pseudoaddiction?
Read:
Pseudoaddiction versus addiction in a pain population
(great Master's Thesis by my friend Ann
Kline) |
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