Re-thinking the Landscape of Addiction Treatment.
The Analogy of Addiction Treatment:
Addiction treatment is not always treatment. Common definitions of treatment include “medical care given to a patient for an illness or injury,” “a session of medical care,” or “the administration of a dose of medicine.” We often call rehab programs “addiction treatment” – sometimes it is, but it is quite different than treatment a medical team would provide to someone after being diagnosed with cancer, diabetes, heart disease, or even a series of broken bones.
Let’s put it in context. You break your hip and head to the emergency room, where a physician checks you out, provides some medication for the pain, and you are directed to a room to sit with about 50 other folks. Each of them also have broken hips. If you’re lucky, a doctor comes in, but it’s most likely a nurse or medical student. They spend an hour talking about how to avoid dangerous situations; in a perfect world, they even ask you to identify where you went wrong with your own accident. After that group, you are shuffled to a different room for an hour-long group that explains to you all the different types of procedures clients could utilize once leaving the hospital, like having your hip healed through physical therapy or reconstructive surgery. Then everyone is escorted to the gazebo for a cigarette, then lunch, then to another group where they have you paint a rock to describe your feelings about what it was like to break your hip.
You are shuffled about day after day, talking about the problem and talking about what the solution is. But never do you actually start working on the solution. Why? Because you will only be there for 20-30 days and the truth be told, there really isn’t enough time for you to find real world applications for what is being discussed.
In 1939 the book Alcoholics Anonymous talked about this very same idea. Please click on the link to read a few short paragraphs discussing this very same idea. Reference the Jay Walker in Ch 3 of from the book Alcoholics Anonymous. Page 37-38
The Forgetting Curve – Don’t Forget that Last Drink/Drug!
Hermann Ebbinghaus was the first to study forgetting behavior in a scientific way. At the time, his research was absolutely groundbreaking but today it seems to be forgotten and lost. But it really is critical for us to understand this information when helping addicts and alcoholics.
His findings were published in 1885 in his book Memory: A contribution to Experimental Psychology. His research suggests that initially your memory retention is 100%, as this is the point in time when you actually learn the piece of information. As time progresses, the retention rate drops sharply to around 40% in the first few days. It also shows that the forgetting curve is exponential – the most significant memory loss occurs in the first few days. A person will continue to forget over time, but at a far slower rate.
Ebbinghaus found that the rate at which you forget depends on some factors:
- How difficult is the learned material? How easy is it to relate the information with facts which you already know?
- How is the information represented/presented/interpreted?
- Under which condition are you learning the material? Are you stressed?
- Are you fully rested and have you slept enough?
Columnist Art Kohn writes that the research on the forgetting curve shows that within one hour, people will have forgotten an average of 50% of the information you presented. Within 24 hours, they have forgotten an average of 70% of new information and within a week, an average of 90 percent of the information. He notes that this percentage may vary based on the person, but the overall result is disconcerting.
Transfer this into addiction “treatment,” which is more or less a 20-30 day crash course and stabilization founded on a theory that includes avoiding people, places and things that might cause relapse. We are stunned by the high relapse rates in substance use disorder. Can you imagine…walking out the door and forgetting 70% of the information within 24 hours.
Is Being Accepted by Peers More Important Than Being Clean?
Think about some of those previous reasons someone may forget the information. Then consider a statement made by Thomas Merton in his 1966 publication Conjectures of the Guilty Bystander. Merton states, “For we need one thing more than happiness: we need approval. And the need for approval destroys our capacity for happiness.” Where do you think this statement applies to our 18-35ish addicts and alcoholics? Let’s keep in mind that the client’s maturity and impulse control has been stunted by substance use. How many times have you seen someone influenced by their peers? What do you think is considered “cool” in a treatment center – the guy sitting in front, taking notes and asking questions or the guy sitting in the back, talking to the pretty girl, cracking jokes and talking about that epic war story?
Now imagine sitting in treatment at 23 years old after using for the past 5+ years. It’s possible that you understand the importance of sobriety in your life, but you also value belonging to a crowd, having friends and a social life. Maybe you are interested in getting clean, but you go home on a Friday night to a supportive family but no real peers to have a good time with. You spend hours on social media, inundated with images of your old friends on Instagram and Snap Chat. How long do you think your “recovery” will last?
Let’s also consider motivation to change. A person goes to treatment with a group of folks in the same age group. The major concern is to be perceived as cool and likeable, yet water seeks its own level, so the people perceived as “cool” and “confident” are unmotivated and believe recovery is a joke. They believe “just not using” will be enough.
The group facilitator comes in and presents, but before the group, at the smoking hut and during the day’s free time there is plenty of time to allow peers to convince someone that the professionals don’t know what they’re talking about and it’s all a waste of time. “Hey, marijuana is going to be legal anyway!” When the patient returns home, they’ve already forgotten a significant portion of the information they learned during their treatment stay and it becomes very easy to fall back into active addiction.
When there are all these other noises around it becomes extremely difficult for people to stay focused on what is important at that time. For instance take this video for example
Selective attention test
From a psychological and neurological perspective, addiction is a disorder of altered cognition. The brain regions and processes that underlie addiction overlap extensively with those that are involved in essential cognitive functions, including learning, memory, attention, reasoning, and impulse control. Drugs alter normal brain structure and function in these regions, producing cognitive shifts that promote continued drug use through maladaptive learning and hinder the acquisition of adaptive behaviors that support abstinence.
Dr. Thomas Gould believes that “addiction represents a pathological usurpation of the neural mechanisms of learning and memory that under normal circumstances serve to shape survival behaviors related to the pursuit of rewards and the cues that predict them.” Therefore, it is safe to say that he believes, as an addict, sitting in a few groups and trying to learn why it’s a bad idea to go home after 20ish days is bound to fail the first time. When the entire brain has been rewired to seek fast, easy pleasure in the same way that a person would seek food, water, or safety (those “primal” instincts), it takes a lot of concentrated effort to create lasting change.
He goes on to say that individuals in deeper stages of the addictive process present additional clinical features, including withdrawal symptoms during early abstinence, persistent vulnerability to relapse, and alterations in decision making and other cognitive processes. Reaching this stage of the addiction process is not necessarily contingent upon length of use, as we often see the progression of substance use disorder in young adults is just as disruptive to the brain (limited impulse control, inability to consider the consequences, etc.). When a person displays these additional clinical features, it is critical to engage them in resources beyond “just not using,” as this is not sustainable when the brain chemistry has been so dramatically altered. It’s important that we do not limit their course of treatment to being surrounded by unmotivated individuals, going home to an unstructured environment, being bombarded/distracted by social media and other potential disruptions to one’s attention and treatment.
Further on, Gould explains that modification of the dopaminergic reward system remains important at the lesser stages, but is probably is not sufficient to maintain these complex and long-lasting changes. This means that early interventions and straightforward treatment models may be effective in prevention or limited exposure (like using drugs a handful of times), but it’s not enough to create sustainable recovery for a person who has been inexplicably changed by substance use. If a mother tells the clinician, “I don’t recognize the person my child has become,” that’s an immediate red flag that they have experienced the deeper stages of the addictive process. Therefore, “treatment” needs to be longer, deeper and include exponentially more than what we are currently offering in our typical 28 day programs or our Partial Hospitalization Programs.
Lastly the doctor writes “the full extent of drugs’ impacts on cognition is not yet known, but research indicates that addicted individuals have alterations in brain regions including the striatum, prefrontal cortex, amygdala, and hippocampus. These same regions underlie declarative memory—the memories that define an individual, without which it would be difficult to generate and maintain a concept of self. Drugs’ capacity to act upon the substrates of declarative memory suggests that their impact on cognition is potentially extremely far-reaching.” How many times have you seen folks in early recovery have no idea what they enjoy or who they are? This sense of self and concept of “who am I?” is nagging at most young adults. When coupled with addiction, it creates overwhelming confusion, powerlessness, and discomfort.
MAT in Addiction Treatment
It is important to acknowledge that this article is neither in support of nor opposed to Medication Assisted Treatment (MAT). MAT is effective, but we can argue that in many circumstances it does not create a complete change of life. For some it is the catalyst that allows a client to take the time to initiate rebuilding, but over MAT is a block on the physical compulsion that does very little to combat the mental obsession that is always behind the first drink/drug. If MAT was sufficient, we would not see a rise in cocaine/amphetamine use with addicts on Vivitrol. We would not see a rise in benzodiazepine use in methadone patients and we would definitely not see individuals on Suboxone sell it and use heroin intermittently.
The Idea of Powerlessness and the Need for Sanity Restoration
Step One of all 12-step programs talks about being powerless. This article has already referenced significant research that implicates the importance of engaging in a 12-step program and embracing this idea. When we look at the basic definition of the word we see that no real addict or alcoholic, on their own power, has the ability to have full control, choice or power. If someone has not “fallen down the scale too far” (meaning their brain chemistry has not been so drastically altered), they may still have the ability to choose to get and stay clean. However, once the addiction truly has a hold on them, the idea that they will simply use their will power, have a choice to never use again or start controlling their use is utter insanity.
If our young adults continue to go to a 28-day program then return to the place they were using they are almost guaranteed to be unable to stay clean and sober. It would also be safe to mention that if they continue to return to the same addiction treatment program or detox, again and again, once they relapse they will be more likely to continue the cycle of relapse.
If our young adults continue to attend 28-day programs and immediately return to the place they were using, it is almost guaranteed that they will be unable to stay clean and sober. It would also be safe to mention that if they continue to repeatedly return to the same addiction treatment program, again and again, once they relapse they will be more likely to continue a cycle of relapse. When a person makes friends in treatment, and together they acquire a period of clean time but eventually begin using again (perhaps they even use together!), it suddenly becomes incredibly complex for the client to discern whether this friend is now one of the “people, places and things” to avoid. A person who was just a sober companion became a using buddy – is it safe for them to try to get clean together again? And if it’s difficult for us to answer that question, imagine how complicated it feels for the client!
Now picture this. Johnny is in his second treatment center. He has been using opiates and alcohol for 5 years. He is 24. He has never maintained any real employment, has not been able to finish college and has been living at home. His mom and case manager sit with him and present a few options for aftercare. One is going home and doing IOP, another is attending a long-term program. Then the real bomb drops….they say “which do you want to do?” This sentence/question nearly signs his death certificate. Think about it. Why, with everything we know, would we allow someone who is slowly killing themselves to make that decision?
To think that 28 days, a quick detox, or even coupling a 28-day stay with a few IOP sessions per week will be enough to re-wire a brain that has been submerged with drugs and alcohol for multiple years shows a failure on our part to understand the complexity of substance use disorder.
Folks that have fallen down into the trenches of addiction need a full restoration. Yoga, exercise, talking about the problem and avoiding people, places and things are all well and good, but it’s a far cry from a restored mind.
There needs to be a full shift, an entire re-arrangement of mind, body and spirit for someone to recover from addiction.
Action Based Solutions
SAMHSA reports that making the Eight Dimensions of Wellness part of daily life can improve mental and physical health for people with mental and/or substance use disorders.
Wellness is being in good physical and mental health. Because mental health and physical health are linked, problems in one area can impact the other. At the same time, improving your physical health can also benefit your mental health, and vice versa. It is important to make healthy choices for both your physical and mental well-being.
Serenity is not about not having problems. It is about feeling calm, centered and balanced while in the center of the storm.
Remember that wellness is not the absence of illness or stress. You can still strive for wellness even if you are experiencing these challenges in your life.
- Emotional—Coping effectively with life and creating satisfying relationships
- Environmental—Good health by occupying pleasant, stimulating environments that support well-being
- Financial—Satisfaction with current and future financial situations
- Intellectual—Recognizing creative abilities and finding ways to expand knowledge and skills
- Occupational—Personal satisfaction and enrichment from one’s work
- Physical—Recognizing the need for physical activity, healthy foods, and sleep
- Social—Developing a sense of connection, belonging, and a well-developed support system
- Spiritual—Expanding a sense of purpose and meaning in life
Long-Term Cost Effective Options for Addiction Treatment or Recovery Program
It is imperative that in 2018 we find new methods of long term options for young adults dying from addiction. While lecturing in two different addiction treatment centers, in front of on average of 100 people each week, it is easily observable that majority population is between 18-35 years old. This group is easily impressionable, stubborn and incredibly active on social media. This group will continue to fail if we continue to think that only 28 – 60 days is enough to bring them out of the fog created by 3 or more years of active drug and alcohol use.
Not only does this group suffer from addiction but due to other psychological issues, like personality and overall motivation, attrition from substance abuse treatment is a major barrier for successful outcomes typically defined as reduction or cessation of substance use and improved psychosocial function or physical health. A peer reviewed journal article posted in the U.S. National Library of Medicine explains that the first-month attrition in outpatient non-methadone substance abuse treatment programs is approximately 30% and the drop-out prior to 3 months can be 50% or more. Many believe that 3 months is the minimum to see real symptom improvement and length of time in treatment has been associated with positive treatment outcomes. We need to look at what we are doing wrong.
We need attractive year-long programs that incorporate the 8 dimensions of wellness into the recovery program. Why? Because it is action-based and gives the addict/alcoholic something specific to do, rather than simply presenting information. It is solution based vs. problem specific. Looking for solutions keeps the mind focused on what to do next but in a positive manner. When we focus on the past, particularly with addiction, our minds forget the pain and tend to only remember the positive times during drug use. This creates the obsession to use.
We know by looking at the history of Alcoholics Anonymous that being told what to do does not work; it is not until the addict/alcoholic is willing to take action and given concrete direction to transform their life that change takes place. Individual and group-based clinical work is necessary, but consideration of the learning curve allows us to better understand the limits of these models.
Dr. Michael Miller, a board certified addiction psychiatrist, discussed Twelve-Step Facilitation therapy in a piece for the American Society of Addiction Medicine in 2015, suggesting that it is still a tried-and-true proven approach to long term recovery. He writes that it is far more then advising a patient to “go to AA” and giving them a list of meeting times and locations. Twelve-Step Facilitation is the active probing, nudging and encouraging not only of attendance, but also participation in meetings and the program; it explains the potential benefits of working with a sponsor and promotes the individual developing a relationship with a sponsor; it explores problems or psychological resistances to attendance, participation, actual “working the steps,” and the development of a sponsor-sponsee relationship; and it opens the door to “AA-related activates” such as volunteer service to one’s AA “Home group” and involvement with AA related social events, retreats and local and state conventions.
If the current barriers are appropriately broken down to make 12-step recovery accessible by our young adults and use 8 dimensions of Wellness as the backbone of the program, this is what we will find in a program:
- Emotional—Coping effectively with life and creating satisfying relationships. The addiction treatment or recovery program would be 1-4 hours from the person’s major adult support system, assuming this is the family. It would encourage healthy dialogue and contact. It would work with the family regarding boundaries and have regular contact that encourages the addict/alcoholic and assists with holding them accountable; which will build self-esteem and a sense of accomplishment. The 12-step piece would create and enhance effective coping skills and the ability to connect with peers in a positive way.
- Environmental—Good health by occupying pleasant, stimulating environments that support well-being. Again, the family would be within a day’s drive. This would also help the person to want to stay in the area they are building their recovery. Often we see folks come back to an area after being away for multiple months or years and begin to use again. Being positioned in an area that will allow someone to visit family monthly will quiet the urge to leave the program. Other environmental factors include eliminating persons with no motivation, fostering positive relationships by promoting and facilitating stimulating activities.
- Financial—Satisfaction with current and future financial situations. Quality programs would create community service activities that would build work ethic and give the addict/alcoholic additional skills. They would also help clients build resumes and offer other vocational education and teach practical skills, such as interviewing. The ability to implement budgeting would also be needed, as this population has very limited understanding of the value of a dollar.
- Intellectual—Recognizing creative abilities and finding ways to expand knowledge and skills. The actual working of the 12-step process will allow the person to look inward and ask themselves some of life’s bigger questions like “what do I really want to do with my life?” If implemented appropriately, the client would be encouraged to help new clients and “show them the ropes.” This continues to foster self-esteem, a healthy sense of pride and allows them to share the knowledge and skills they recently acquired.
- Occupational—Personal satisfaction and enrichment from one’s work. Occupational will almost always be directly proportional to the person’s past experience. That being said, a program utilizing the 8 Dimensions of Wellness would implement community service opportunities to give clients skills, promote and encourage continued education and allow for that to happen. There would need to be opportunities available for folks looking to find jobs and go back to school.
- Physical—Recognizing the need for physical activity, healthy foods, and sleep. The program would include comfortable rooms that are not overcrowded and cramped, comfortable beds with clean sheets, the ability to do laundry on a weekly basis, and adequate food that is healthy and nourishing, including healthy snack options throughout the day. The program would need to provide multiple weekly, if not daily, activities that promote physical health. These activities would need to be stimulating and would ideally promote hobbies that the client could continue once they transition to a different living situation. 12-step recovery would also provide a stimulating outlet for friendship and provide some activities for those willing to engage.
- Social—Developing a sense of connection, belonging, and a well-developed support system. Like mentioned in some of the other Dimensions, 12-step recovery would provide a sense of connection and belonging. Engaging daily with a sponsor and a network of like-minded peers fosters this sense of belonging and generates the support system.
- Spiritual—Expanding a sense of purpose and meaning in life. The spiritual component most likely will need to come in the form of education and will be enhanced through the practical application in the 12-steps. One of the major positive factors in the 12-step approach is the ability to turn around and show someone else. The ability to sponsor gives folks an impactful feeling of gratitude and a sense of accomplishment. Quality addiction treatment or recovery programs should at least educate clients/residents on the importance and history of the 12-step approach. These activities combined with many aspects above provide a deeper meaning in life.
When a recovery program and aftercare plan is rooted in the 8 Dimensions of Wellness it can provide someone a solid foundation in recovery. It becomes so much more then “just avoiding the first drink or drug” and it has to be more then that, because that is not working. If you are looking for viable options for addiction treatment or long term recovery programs please reach out for help.
If you want more information on Surfside Structured Sober Living and our young mens Life Development Program please click here.