An Improved Model of Substance Abuse Therapy

 In Substance Abuse

A new client come in last week, recently discharged from an inpatient facility, and after talking about what his program was like and what he learned, I told him, “Yeah, I need you to forget everything they told you.”  That is a common occurrence. In my office, therapy for addiction related issues focuses heavily on education. I load people up with research and we walk through why I need them to forget what they have been told. I want them to understand that they are not powerless over their addiction, that their life is not unmanageable, and that they do not have a disease that, to a large degree, controls their behavior.  Those three ideas are the cornerstone of empowerment.

This post is the first step in laying out those ideas in a comprehensive fashion. It is an overview of several areas in which I believe addiction therapy falls short. The first area, and the subject of next week’s post, is the problem with labeling addiction as a disease.

Unfortunately for everyone, addiction treatment hasn’t changed much over the past 40 years.

Treatment facilities and clinicians continue to recommend methods that should have been revised long ago. Those asking for help are often treated with a, “one size fits all,” approach that presumes all addictions and all patients to be the same.  This is called the, “patient uniformity myth,” and the term describes the tendency of clinicians to see all members of a category as more similar than they are, ignoring individual differences. Even as a client in my first inpatient rehab, I realized that this was wrong. We were told that we all suffered from the disease of addiction so we were all the same, regardless of our drug history and drug of choice. In a sense that is correct. It is meant to reduce comparative judgement and, yes, we were all there for the same reason.  The problem arises when, based on a qualitative inclusion in a broad category, everyone’s program is also the same. Every substance is different and individuals arrive at a drug of choice through an infinite number of avenues. Failing to fully appreciate the impact of environmental contextualism, social constructivism, and histories of trauma can significantly reduce treatment efficacy. The truth is that there is not one, “addiction,” or one, “alcoholism.” There are as many of each as there are people and any therapist must recognize the need to tailor services to the individual.

Let’s look at some things you won’t hear about from most addiction professionals.

  • What if I told you that we don’t have to call addiction a disease to avoid stigmatizing an addicted person?
  • What if I told you that the belief that addiction is a chronic, progressive, brain disease can increase the probability of relapse and, despite what you’ve been told, is false (Miller, Westerberg, Harris, & Tonigan, 1996) (Lewis, 2015)?
  •  What if I told you that the average life of a diagnosed substance use disorder could be plotted along a distribution curve and differed depending on the specific substance (Heyman, 2013)?
  • What if I told you that most people currently labeled as addicts and alcoholics will quit using, and will do so without any form of treatment.  (Price, Risk, & Spitznagel, 2001)?

 

All the above statements are currently supported by peer-reviewed addiction research, but there is a large disparity between what addiction research is currently demonstrating and what most treatment centers and therapists are practicing.  

A word of warning, however; if you choose to address this issue with most practitioners, be ready for anything from indignant confusion to condescending dismissiveness. Unfortunately, addiction as a disease has in many cases become a deeply held personal belief with enormous inertia. It has been repeated so often, and for so long, and with such conviction, that rebuttal often seems to be an exercise in futility.

The idea that we need to reduce stigma and increase empathy is noble in purpose, but it does not necessitate the leap to chronic, progressive disease. As someone who struggled with drugs and alcohol for over 20 years, I would rather you think I’m a bad person than, for the rest of my life, carry around the belief that I have a chronic, progressive, incurable, relapsing disease. It seems a lateral move at best.

But what of all the research that claims to prove that the above qualities are true of addictive disorders? 

Gene Heyman (2013) puts it like this:

“In the half-century that has passed since “Maturing Out of Narcotic Addiction” was published, hundreds of papers on remission and relapse have been published. They support the following simple generalizations. Many addicts keep using drugs well into old age or until they die (e.g., Brecher 1972, Gossop et al. 2003, Hser 2007, Hser et al. 1993, Vaillant 1973). These addicts typically entered the research literature as subjects in treatment follow-up studies. Conversely, at least some addicts quit after a few years and do so without the benefit of treatment (e.g., Biernacki 1986, Toneatto et al. 1999, Waldorf 1983). These addicts typically entered the research literature as subjects in studies of nontreatment populations. That is, it is easy to find treatment follow-up studies whose results support the widely-held claim that addiction is a   chronic, relapsing disease and that addicts need lifelong assistance, and it is also easy to find community studies whose results support the notion that addiction is a time-limited disorder that somehow resolves on its own. These results need not be in conflict. In principle, they are simply the opposite ends of a distribution of time-spent-addicted durations: Some drug users quit early; some quit late. Indeed, this is the principle that guides this review (p. 32).

This should not be understood to mean that treatment is not beneficial.

It is true that most substance abuse issues work themselves out over time, but some do not, and even when they do, it can be a pretty long time. So, if you don’t want to just sit around until you hopefully stop being addicted, you may want to at least discuss that with someone. However we choose to address the issue, we must take a holistic approach that utilizes methods from psychotherapy, case-management, and coaching.  Meeting the client where he/she is, and empowering the client is key. Individualized goals and objectives are prioritized and client and counselor begin implementing positive change in any number of different areas.

 

 

 

Sometimes, we’re just trying to keep someone alive.

It may seem counterintuitive to preconceived ideas, but addiction treatment is not always about the cessation of use. We may not like (or agree with) that reality, but it is, nonetheless, the reality of substance abuse treatment.  In December of 2011, SAMHSA announced a working definition of “recovery” from mental disorders and substance use disorders:

“A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Is it surprising to notice that a complete remission of symptoms is missing from a definition of, “recovery?” The omission is intentional and reflects the idea that we can improve functioning within any number of domains, even if we aren’t initially successful in completely eliminating the disorder. Refusing (or terminating) treatment or therapy because an individual is not immediately ready or willing to commit to total cessation of use is akin to refusing service to a client suffering from generalized anxiety disorder who refuses to, “calm down.” In each case, treatment of the disorder is made conditional on the person responding as if they did not have the disorder. It is unfortunate that so many providers require total abstinence as a prerequisite of treatment when doing so excludes many from potential sources of support and increases harm to both the addict and the community. Willenbring (2000) supports this view:

“Long-term abstinence from drug use is, of course, the optimal goal. It is a cure with permanent remission from the symptoms of drug dependence. Historically, any goal short of permanent abstinence was considered a failure. Cure is not always possible, however, and it is not the only outcome that may represent improvement or response to treatment. Temporary cessation or reduction of use, reduction in symptoms of addiction, or reduction in severity of co-existing problems are all improvements short of cure that are nevertheless worthy of pursuit. To accept a goal short of permanent abstinence is pragmatic, not “enabling,” because it is realistic and appropriate, considering the natural history of the disorder. Approaching addiction realistically allows psychiatrists to do what we can (which is often quite a bit), while accepting that our treatments are only partially effective.”

The difficult truth is that no one has the power to change another person’s behavior.

People will not be forced into doing what, “should,” be done based on an outside appraisal of what is, “needed.” Therapy is about meeting a client where he or she is, and helping that client achieve individualized goals. That could include referrals for physical health conditions or psychiatric care, location of resources for housing, clothing, or food, working with state agencies like Family and Children Services or Community Supervision to improve outcomes, in addition to addressing trauma-related issues or co-occurring mental health disorders through psychotherapy.

If you’re confused by some of this information, not to worry, much of the field is also confused. If you have questions regarding different treatment modalities, or what would be a good fit for you or a loved one, give me a call. We can schedule a free consultation and try to come up with some solutions specific to your situation.

 

 

References

Heyman, G. M. (2013). Quitting drugs: Quantitative and qualitative features. Annual review of clinical psychology, 9(), 29-59. https://doi.org/10.1146/annurev-clinpsy-032511-143041

Lewis, M. (2015). The biology of desire: Why addiction is not a disease. New York, NY: Perseus Books.

Miller, W. R., Westerberg, V. S., Harris, R. J., & Tonigan, J. S. (1996, December). What predicts relapse? Prospective testing of antecedent models [Supplemental material]. Addiction, 91, S155 – S171. https://doi.org/10.1046/j.1360-0443.91.12s1.7.x

Price, R. K., Risk, N. K., & Spitznagel, E. L. (2001, July). Remission from drug abuse over a 25-year period: Patterns of remission and treatment use. American Journal of Public Health, 91, 1107-1114. https://doi.org/10.2105/AJPH.91.7.1107

Willenbring, M. (2000, February). Harm reduction for substance abuse in the psychiatric setting. Psychiatric Times, 17(2). Retrieved from http://www.natap.org/2004/HCV/062304_05.htm

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