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Top Five Things You
Should Know About Addiction |
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One:
Understanding addiction accurately can take you a
long ways
To effectively deal with addiction, it is absolutely
critical to have an accurate understanding of addiction.
This may seem obvious, but unfortunately, many treatment
professionals, researchers, struggling addicts, families and friends of
addicts, as well as the general public, have relied upon
ways of thinking about addiction that are not based on
current science. This in turn, has resulted in disappointing
outcomes, a sense that treatment doesn’t work, and
intervention strategies that are doomed to fail. If you want
to effectively deal with addiction, your first priority
should be to develop the most accurate understanding of this
problem, and then base your interventions on that
understanding.
One of the best
models for understanding addiction comes from Dr. Howard
Shaffer from the Division on Addictions at Harvard Medical
School. His
Syndrome Model of Addiction
provides a concise and useful framework for
starting to explore the essence of addiction. Added to this,
is the fact that addiction - for most people - is a chronic,
relapsing, medical illness. These characteristics of
addiction were notably discussed in an article in the Journal of
the American Medical Association titled
Drug Dependence, a Chronic Medical Illness: Implications for
Treatment, Insurance, and Outcomes Evaluation.
In the article, the
authors compared addiction to other chronic
medical conditions including asthma, diabetes, and
hypertension. When you understand addiction as a chronic
problem - and realize our treatment system is
organized to intervene on addiction as an acute problem - you
begin to see why treatment often appears to not work.
Unfortunately, this article narrowly focuses on drugs, but
the ideas are applicable to all addictions.
To really
understand something is to know "what causes what." This
ultimately is the goal of theory (versus models). In the
field of addiction, there are many, many theories about what
causes addiction, but most focus on particular aspects of
addiction, and rarely address the "causes" in a
comprehensive framework. There are some notable exceptions,
however, and these theories provide our best understanding
to date about addiction and how best to intervene. In 1985,
Dr. Jim Orford published
Excessive
Appetites: A Psychological View of Addictions
that he updated in a second edition in 2001. Although
written much more for researchers and clinicians, it
brilliantly illustrates the complexities in truly
understanding a very perplexing problem. More recently
(2006), Dr. Robert West published
Theory of Addiction, that insightfully
builds upon prior theories, but goes beyond them
by understanding addiction as
abnormalities in the human motivational system.
While these reads may be challenging for some, they have a
lot to say about intervention which is why they are worth
the effort.
Finally, this
site provides another perspective on
understanding addiction that utilizes the
insights from the above publications. If you invest the time
in reading about these models, theories, and ideas, you will
have taken a significant step in not only
understanding addiction based on current science, but on
uncovering the leverage points necessary for successful and
lasting change.
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Two: Long-lasting solutions for addiction
require a management approach
Ideally, how we
intervene should be directly linked
with how we understand the problem of addiction. Having
invested the time in reading the above publications and
links, you now know that addiction is a chronic, relapsing,
medical condition, that most often involves excessive relationships
with multiple objects of addictive behavior, and is associated with a wide-range of
co-occurring disorders (e.g., mental health, legal, social,
medical, employment). You know that it most often begins
during teenage years, and then comes and goes to varying
degrees over the life course. Like other chronic medical
conditions, it is not a problem that can be expected to go
away after an initial treatment episode - or even multiple
treatment episodes - but must be managed appropriately
over the lifespan. Treatment can play an important role
in the long-term management of symptoms, but for treatment
to work, it must be connected with a broader
long-term plan.
Common wisdom holds that addictive disorders require
professional treatment to help a person establish a life
built around "being in recovery." Some would also add that a
life of recovery is established by aftercare participation in
self-help groups like Alcoholics Anonymous (or NA, CA, SA,
GA, OA) or SMART Recovery meetings. Although expert
treatment and self-help meetings clearly help many people
with addiction, they do not represent the way the
majority of people deal with addiction. More than 80
percent of those identified with an addiction never receive
any type of formal treatment. Moreover, the language of
"being in recovery" is unique to particular self-help
ideologies (AA) whose total group membership sees less than
five percent of all those who struggle with addiction. The
idea that the optimal (and only) way to deal with addiction
is by utilizing professional treatment and self-help
meetings has culturally become a norm that many don't
question (or even know enough to know that they should
question it).
Bottom line, the overall goal of
intervention should not be object-specific, or acute-based,
but focus on all the different objects a person
uses in an abusive, excessive, or addictive way - over the
course of their life. In this way, the general goal of
intervention is very much in line with how we address other
chronic medical conditions – it is based on “symptom
management” over the lifespan. Management of
addictive behavior may involve very specific treatment
episodes – outpatient and residential – but in general, the
management approach is based on
processes of change that we
all use to change behavior whether part of a professional
program or not.
One of the best
summary articles specific to a management approach is by
William White and David Loveland. Unfortunately, the article
is not in a form that I can link to, but is well worth the
effort to visit your local library and get a copy. Here is
the reference:
White, W.,
Boyle, M., & Loveland, D. (2002).
Alcoholism/Addiction as a Chronic Disease: From Rhetoric to
Clinical Reality. Alcoholism Treatment Quarterly.
20(3/4) 107-130. (Also published in McGovern, T.F. & White,
Eds. (2002), W.L. Alcohol Problems in the United States:
Twenty Years of Treatment Perspective. New York, The
Haworth Press).
However, the authors have published on-line a brief summary
of the
recovery management approach that will get
you started.
Another useful
read is
concurrent recovery monitoring, that
offers a nice framework for thinking about how our current
addiction treatment system can incorporate principles of
addiction management in the care of those with addictions.
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Three:
Addiction treatment can play an important role in the
long-term management of symptoms - but the current system is
not without its problems
Although most (perhaps 85 percent) who struggle with addiction will never
receive any type of professional treatment, it is not
because formal treatment is not effective. In fact, there is
a plethora of research that shows that addiction
treatment is a very good investment. Most who enter
treatment reduce or give-up there addictive behavior, and
show remarkable progress on a number of important life
indicators (e.g., mental health, career, family, legal,
social, physical). However, a key point is that treatment
works while someone
is in treatment.
Unfortunately, our current addiction treatment system is
still (despite the research) set-up to treat addiction as an
acute (short-term) problem. Most who struggle with addiction
will often complete treatment within days (in the case of
residential) or months (outpatient) of entering, and in rare
cases will receive treatment longer than a year. Once
discharged, many (and perhaps most) return to some form of
addiction because it is a chronic condition that must be
managed over many years - often decades - just like other
chronic conditions. So there are some real significant
problems with our current treatment system, and questions
that need to be resolved, including:
- How do
we change the current treatment system from an "acute
treatment focus" to one that utilizes a "continuance of
care model" where those who struggle with addiction stay connected to
some form of care for years?
- Who will
pay for care that will extend over many years? Better
yet, how do the various funding streams of addiction
treatment put their heads together and develop a better
system of reimbursement that is similar to how we fund
care for other chronic illnesses?
- How do
treatment programs dynamically change what they do with
clients over the months/years to accommodate the changes
that occur with clients (i.e., as clients progress in
treatment and get better)?
Additionally,
it is important to understand that although treatment
works (in the sense that while people are in
treatment they do better in life), research indicates
clearly that many serious problems exist with our current
addiction treatment system, including:
-
Of the 25 to 30 million
people who struggle with addiction, only about 15
percent receive any type of professional intervention.
In other words, our current system sees the minority of
those in need.
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Many working
in the treatment field lack an accurate
understanding of
addiction, knowledge of
systems evaluations,
or how to provide
developmentally
based psychotherapies necessary for
long-term successful treatment outcomes.
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The
workforce turnover rate in community-based treatment
programs is higher than in the fast-food industry.
The pay is often low, paper work demands are high, and
programs are increasingly asking clinicians to do more
with less. Those who work in the field often lack a
graduate-level education, appropriate clinical licenses,
and often are not trained to diagnose and treat mental
health disorders (that co-occur with addiction ~75
percent of the time).
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The current
system is incredibly fragmented and compartmentalized,
with gaps between: 1) primary care medicine and
addiction treatment, 2) evidence-based practices and
current care delivered in many programs, 3) the legal
system and clinicians, 4) those who focus on substance
addictions and those who focus on behavioral or process
addictions, and 5) public policy makers who have an
incredible influence on the treatment system (and yet do
not deliver treatment) and those who deliver treatment
(clinicians) but have little influence on the treatment
system.
All this to say
that our current addiction treatment system has many
problems. In 1998, a landmark publication titled
Bridging the Gap Between Practice and Research
brought many of the above issues to the forefront of the
field, and led to the most ambitious attempt in history to
bring science to clinical practice. The publication led to
the formation of the
National Drug Abuse Treatment Clinical Trials Network,
a massive effort to bridge the gap between research and
practice. Although many good things are emerging from this
effort, enormous
challenges lay ahead in overhauling our current treatment system.
The take away
message is that treatment is not perfect, but despite the
shortcomings found in our current system, there are still
many remarkable clinicians and programs that do very good
work. For someone struggling with addiction, it is important
to understand the above mentioned problems, and proactively
take steps to incorporate treatment into a long-term
management plan.
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Four: The
single most important factor in successful management of
addiction is the ability to initiate, develop, and maintain
healthy intimate relationships
The reason, is that at the
center of a good life, are intimate human relationships.
Although many who struggle with addiction often have many
great people in their life, very often they lack the
developmental skills to know how to appropriately engage
with those people in healthy, intimate ways. As a result,
relationships are usually strained, and often play a role in
perpetuating addictive cycles. In sum, addicts settle on
relationships with objects instead of people because the
objects: 1) make them feel good or feel better (at least
initially), 2) require no relationship skills, 3) are
ubiquitous, and 4) do not demand the effort human
relationships require. Therefore, the overall goal of
long-term management of addictive behavior is replacing
relationships with objects (drugs, poker machine, porn,
food) with healthy, intimate human relationships. This
necessitates having the
developmental skills to initiate,
develop, and maintain such relationships that usually are
lacking in those with addictions. Although part of
intervention is focused on stopping destructive addictive
behavior patterns, the real therapeutic work involves
obtaining the developmental skills necessary to succeed in
human relationships. Most often, this requires
developmentally based therapy that
is rarely found in most professional treatment
programs. It is also worth noting that although 12-step and
other self-help groups can provide valuable human
interaction, most who attend meetings have not received
developmentally based therapy, and thus provide little help
in gaining the necessary relationship skills because they
remain developmentally constricted themselves.
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Five: If you struggle with
addiction, there are many reasons to have hope
Addictive behavior has been around for centuries, and will
likely be around for centuries to come. It is part of the
human condition, our culture, and greatly a product of the
times. This is good, because today, how we understand and
deal with addiction is much different than 100 years ago,
and it will likely be very different in the future. The main
reason is that science is very interested in addiction, and
for years has made considerable progress in understanding
excessive behavior and how to successfully intervene.
Perhaps most frustrating, is that the treatment system has
not kept up with the research, and today is in need of
significant change. If you spend time on this web site, and
read the linked publications, you will find many reasons to have
hope. Those who struggle with addiction will find:
- Accurate
information based on science that often contradicts
common ways of thinking about addiction and intervention
- A way to
understand addiction that is in line with science and
paves the way for interventions that work over the life
span
- Reasons
why prior treatments have failed, and where the best
leverage points are for successful and lasting change
- A
community of committed researchers, clinicians, and
public policy makers who are committed to improving
addiction treatment, and are working hard to replace
ineffective intervention strategies with evidence-based
practices that work
- That
success largely depends on learning how to have
successful relationships with others - something anyone
can learn if they understand correctly what it is that
they need to learn
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