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If you recall the Ebola crisis and the impending destruction of the planet that was unavoidable due to said crisis, then you may also recall expert testimony that the real danger was “if the disease mutates”.  In the case of there was a significant concern that Ebola would mutate to airborne transmission.  The world was not ready for the disease to manifest itself in that way.  Essentially there were zero protocols in place to managed an “airborne version” of Ebola.  Disease or viral mutation is not uncommon.  It happens with influenza.  People are concerned it will happen with A.I.D.S.  In those cases, the mutation will happen at a cellular or genetic level.   Is it possible that addiction could mutate?  Obviously, not at a cellular level but could it manifest itself in a fundamentally different way with an entirely new set of concerns.  Furthermore, are we ready to respond to these mutations?  I would say it already has.  Do we have protocols in place to respond to an “airborne version” of addiction?   I think we have serious work to do in this area.

Historical Context:

I am not a recovery historian by any means.  There are many people who have a deeper understanding of the way addiction has been handled by society.   See William White’s epic Slaying the Dragon for example.   That’s not my purpose in this blog post.  However, it is important to have an understanding of how our current drug and alcohol provider system has evolved over time.  Of course, it is impossible to provide this context in a completely objective manner.  My personal experience and interpretation of the “historical context” will come into play.

Addiction has been around from the dawn of time.  “Ancient Greek remedies for alcohol use included placing an eel at the bottom or the unfortunate drinker’s generous goblet of red wine” (Miller, Carroll, 2006).   History has seen problem users “whipped, dunked, shocked, poisoned with potions, chained, dialyzed” (Miller, Carroll, 2006).  In 2016 we have the Philippine dictator, Rodrigo Duerte, openly talking about killing 3 million addicts to clean up that country.

There have been successful and compassionate remedies to addiction over the years.  In addition, it is a fact that many people recovered on their own or with non-traditional help.  I would imagine that millions stopped the destructive use of drugs through supportive relationships.  Many found their way through church or through unofficial mentorships.  I believe traditional psychotherapy was probably helpful in mitigating addiction over the centuries.  These people did not classify themselves as “recovering” they simply went about their lives without the presence of alcohol and drugs.

As many of you know, the early 20^th century saw the advent of Alcoholics Anonymous.  This mutual support program became the first program to gain substantial reputation as a remedy for alcoholism.  There may have been many who recovered prior to AA, however, there was no specific program they could point to and say “this is how I did it”.  Alcoholics Anonymous grew rapidly and now stands at more than 2 million people nationwide.  AA is a phenomenal program.  But remember, AA was developed as a mutual support program.  A non-professional, free, program of one alcoholic helping another alcoholic.  However, the strangest thing happened along the way.  AA became the cornerstone for all addiction treatment programs.  It remains that way today.  90% (probably more) of treatment programs in America rely on the 12-step programs as foundation for their programming.   But more on that later.

As AA took off, and other anonymous programs came on board-most notably Narcotics Anonymous, the addiction treatment industry started to come of age.  Clearly a business model or “treatment model” had to be developed.  If treatment was going to be professionalized and seen as a healthcare procedure it needed a clear approach.  Also, it seems clear that if people are going to “pay for it” there needs to be a professional model that makes sense.  It was completely natural that that the industry would rely on Alcoholics Anonymous as a guiding light during 1950’s.  Alcoholics Anonymous was the pathway that was most well-known at that time.  AA had stepped into the void with a willingness to help alcoholics and an apparent solution.  The 12-step world spoke with authority regarding addiction and the organization was willing to work with emerging treatment centers. The Minnesota Model was born and utilized at Pioneer House in 1948, Hazleden in 1949 and Willmar State Hospital in 1950.  All these facilities were in Minnesota.  The Minnesota Model brought medical professionals and psychological professionals into the process but AA remained the core of the program.  In his manual on the model, titled The Minnesota Model, author Jerry Spicer put it this way on page 3: “Willmar merged AA principles with a multidisciplinary team: psychologists, physicians, and members of the clergy” (Spicer, 1993).  It is important to note that this model has remained the predominant model of addiction treatment to this day.  Variations and additions to the multidisciplinary team have occurred but the model and approach has remained unchanged at a core level.  For the past 66 years.  But more on that later.  For now, it is clear, modern addiction treatment was founded on 12-step principles and AA and NA are cornerstone of the addiction treatment industry.

As these programs grew another phenomenon took root.  These programs were viewed as successful.  One because there was anecdotal evidence.  Stories of success, even if isolated, became evidence of facts.  There was no real quantitative data. The great recovery historian William White puts it this way:

“Modern addiction treatment came of age in the 1960’s and 1970’s as a community-based phenomenon.  Representation of recovered and recovering people and their families was very strong; AA and NA were the driving force behind this era of addiction treatment.  In addition, there was a perception of treatment efficacy (anecdotal in nature; nonetheless a perceived efficacy) (White, 2006).

The issue of efficacy has since been addressed in a more comprehensive manner but we really don’t know if the model works for the people who do access treatment.  There will be more research in this area and perhaps we can a better sense of efficacy.  Regardless of what we find out in the future we know for sure.  The model exploded and is used by 90% of facilities despite the lack of evidence.  Another phenomenon that drove this growth also centered around effectiveness of the approach.  Unintentionally the business fell into a can’t lose model.  Basically, any relapse or problems post treatment were placed at the feet of the patient.  In other words, if a patient relapsed it was because “they didn’t work the program” or “they were not willing”.  As the cliché says “It works if you work it”.  Ostensibly then, “if it doesn’t work it’s because you didn’t work it”.  The idea something needed to change on the service delivery end was never even considered.  It was a wonderful business model.  It was a wonderful way to launch an industry.  Why would the industry change if everything is going well and outcomes are placed on the patient?  All these factors, and more, have contributed our current state of affairs.  Addiction treatment services are homogenous and, at the core, the same as they were in 1950.  For example, 1998 Study of representative sample of 450 private substance abuse treatment centers found that 90% of the facilities based their treatment on the 12-step principles of Alcoholics Anonymous (Roman, Blum, 1998).  This is the case despite the fact that clear recommendations have been made for alternative approaches and the growing presence of motivational interviewing in the substance misuse arena:

“What we hope to do is to actually have a menu of treatments that clinicians could choose from.  If one drug doesn’t work or they can’t tolerate it,” patients would “try another one and so forth, and hopefully they’ll find one that is effective.” 

–Raye Z. Litten, PhD Associate Director Division of Treatment and Recovery Research National Institute on Alcohol Abuse  and Alcoholism (NIAAA)

Unfortunately, this ideal has not been put into practice.  The stone-cold reality is that anything short of 100% acceptance of 12-step recovery is viewed as non-compliance in the majority of treatment programs in America.  All you need to do is talk to any client post treatment and you will hear the same experience repeated over and over.  For some this experience was positive and “it works” because they “worked it”.  For others, not so much.

It is difficult to move away from deeply held traditional views.  The addiction services workforce is an older workforce.  William White says it this way:

“Many addiction treatment organizations present a profile of long-tenured and graying administrators, clinical directors and senior clinicians combined with an exceptionally high (20-40%) annual turnover of younger, front-line direct service personnel. In addressing meetings of directors of state-funded addiction treatment agencies, I have observed more than three-fourths of those present being over age 45”.

This older workforce was “brought up” on very traditional views around addiction and recovery.  They are not likely to change those views unless compelled.  Of course, this doesn’t mean there won’t be outliers who can see the writing on the wall.  But it is clear that, overall, there is little enthusiasm for substantial change.  Couple this with the built-in lack of accountability centered in a philosophy that blames the patient (“IT works if you WORK IT”) and you have a ship that is going to be very hard to turn.  Why in the world would the addiction services industry do anything substantially different?  There is no real motivation to do so.

This leaves us, at it currently stands, with the same basic approach to addiction.  It is essentially the same medicine that was being administered in 1950.  The Minnesota Model carries the day. I am hopeful that things will change and I hear leaders talking more and more about alternative approaches.

Addiction has changed in many ways, however, I want to focus on the very fundamental issue of progression.  In this case, accelerated progression and how it leads to a demographic and a disease state we are not prepared to address.   

The Accelerated Progression:

• The Progression Has Accelerated: Addiction has always been a protracted progressive process with using career lasting on average 20 plus years and multiple attempts at recovery.  It has unfolded over time in an individual’s life.  Where polysubstance use is concerned (and remember this is the norm) it historically progressed along a relatively predictable path.  Concepts and ideas arose within this context that made some sense at the time.  Waiting until a person “hit-bottom” and waiting until a person “wanted it” was problematic but not nearly as dramatic when it involved a 33 year old who had a good deal of life experience and consequences associated with using.  This made the sit back and wait approach acceptable.  Professional services sit back and wait in a manner consistent with the 12-step philosophy of “go out and do some more research”.  This “progression” also made the total abstinence argument an easier sell.  When dealing with an older person who had used, and many times abused, multiple drugs it made sense to many people in need.  This “normal” progression can be illustrated in the following way:

         In this case the individual start with alcohol at 14 and mixes in other things along the           way ultimately finding recovery after an 18 year using career with 5 distinct and                       genuine “attempts” at recovery along the way.  It may look like he just woke up at age           32 and “rehab worked” but that is not at all the case.  Our current approach (wait until         the pain gets great enough, come see us when you want it) was designed for this dude.

        However, we live in a world where prescription opioids have nearly over-taken                         as drug of first use.  Back in the day it was a relatively unusually experience to have               someone offer you a handful of Xanax or other pills at the age of 14.  Of course they               were “around” but they were not mainstream.  Well they are now.  If you don’t think             they are you are engaging in collective community denial.  The progression has                       accelerated.  Using careers that were on average 20 plus years until arrival in recovery           have been paired down to 3 or 4 years.  The progression now looks more like this:

         In this case our client starts at 14 with weed but is immediately introduced to pills as      well.  Alcohol is an after-thought.  By 16 he is using pills regularly.  We know that               the tolerance and escalation of pills use is rapid.  By 18 he is using pills heavy rarely               smoking weed and alcohol is an after-thought.  Heroin enters the picture at 19 for            “economic” reasons and by 20 he is IV heroin user.  At 21 he enters rehab and is told              to stop all substances and is “held accountable” when he expresses desire to stop          heroin but occasionally drink.  This is labeled denial and treatment resistance because  that is how the model is laid out.  The young person will probably be held back in the          program until he realizes that superficial compliance will get him through quicker                 and with more status.  After all “fake it ’til you make it” is a cornerstone of the                       process.  However when “free” there is little likelihood of follow through.                                 Integration with recovery for the younger age group is exceedingly difficult for this                 group.  Consider the following.  According to Substance Abuse Mental Health Services Administration (SAMHSA), National Household Survey on Drug Use and Health:

      Relatively speaking, youth and young adults represent the largest demographic group           in need:

• At any given time 8.2% of the general population (age 12 and older) meets criteria for substance abuse or dependency.
• However, among 18 to 25 year-olds, the percentage meeting criteria for substance abuse or dependency is 17.3%. Over 2x the rate of the general population.

     And relative to other demographic groups youth and young adults are involved in                    treatment at higher rates than the general population.  For example:

• Among 18 to 21 year olds 8.1% of those in need were involved in treatment.
• For example: As compared to:
  • 26 to 29 year olds: 2.9%
  • 30 to 34 year olds: 2.6%

   However, they seem to be vastly under-represented within the recovery community.  For    example:

• According to the Alcoholic Anonymous member survey less than 1% are 21 or younger and the average age of member is 50 years old.
• According to the Narcotics Anonymous member survey less than 1% are 21 or younger and the average age of member is 43.3 years old.

Interesting dynamic: There are vastly more young people in need and they access treatment more often.  However, they are nearly non-existent (statistically) within the recovery community.

Why higher rates of abuse and dependency?: This demographic includes college age students and the obvious implications of that abstinence-hostile environment contributes to this condition.  In addition, the natural risk taking associated with youth mixed with access to new and more dangerous drugs makes this group more vulnerable.

Why higher rates of treatment participation?:  Parents and other authority figures have influence over this demographic.  They can be forced into treatment more readily than older individuals.  In other words they are made to attend treatment.

Why such low rates of engagement in traditional recovery?: Because our traditional programs are tailored made for middle age white men (average age 50, race Caucasian) and our current treatment paradigm promotes superficial compliance and lacks individualized recovery planning.

The current manifestation, and the coming manifestation, of addiction is fundamentally different than 60 years ago.  Essentially, the default setting for our treatment programs is grounded in principles developed to help middle aged alcoholics with little exposure to alcohol (as discussed above in the exploration of the Minnesota Model and AA’s prominence in the treatment industry).  We are now faced with a younger client population and a compressed addiction process.  A 19 year old heroin addict is drastically different than a 43 year old alcoholic.   We may want to explore ways to provide a fundamentally different type of treatment and addiction recovery services.

Working with younger people is fundamentally different than working with adults.  There will be some young people who do engage in recovery.  There is a growing group of young people in recovery, however, all things considered it is remarkably low participation rate given the potential candidates.  Specialized young adult services goes way beyond a segregated “young person’s unit”.   We need a culture change that moves toward specialized engagement, increased family involvement, and even harm reduction potentialities.  We will discuss these in detail at a later date.  For the time being I would encourage you to think over the reality we are currently facing.  I hope we act before the damage gets too intense.

From its inception FAVOR Greenville has placed great emphasis on the value of “Family Recovery”.  We have swung the doors of our recovery community center wide open to families regardless of the recovery status of their loved ones.  We operate with a few basic principles that have guided our family programming from the very beginning.

1) We believe that there is merit in family recovery in and of itself.  Family members experience profound health concerns when substance use disorders are present.  These include chronic stress, physical problems, sleep difficulties, depression and anxiety.  Even if the person suffering with a substance use disorder never makes a change the family deserves special focus and support to deal with these issues.

2) The family has tremendous power that can be harnessed and focused in a way that increases the likelihood their loved one will seek recovery.  Frequently, when family members start to change the person with a substance use disorder will start to change.  Family systems theory tells us that if you move one part of the family you move the entire family.  Like a mobile above a baby’s crib it is impossible to move one part without impacting the whole. 

3) Family members are frequently the first point of contact in the process of recovery initiation.  Family members constitute a more willing customer base.  They will call for information and options well before their loved one darkens the doors of our center.  They are open to feedback and, in many cases, begging for information and options.  Therefore, FAVOR Greenville sees the family as a ready-made channel for engagement of those in need.

4) Family recovery coaching is a unique discipline and the shared experience of families in recovery can be capitalized on in a manner consistent with basic peer support services.

With these principles in mind FAVOR Greenville started family programs in 2013 with a simple open “Family Recovery Group”.  The group was modeled on basic group facilitation processes of universality, mutual support and mutual respect.  Our initial group attendance was 12 people.  We held these groups every Monday night at 6:30pm.  The group exploded in attendance based nearly entirely on word of mouth.  In 2016 this group averages 54 people per week with a high this past month of 103 people in attendance.  The group has become more didactic and educational in nature.  However, we start each group with questions from the week and we make sure the topic of education/discussion is generated by the group.  There are usually 10 to 15 new people at group and an equal number of “veterans” who have been in attendance since the group started.  Over time an interesting phenomenon arose.  The group was intended for any and all family members.  Spouses, children, siblings and parents together in one group.  However, the group quickly morphed to 90% parents.

In response to this we developed our second family recovery group.  Every Thursday night at 6:30pm we hold our S.O.S. (Significant Other Support) group.  This group focuses on spouses or adult children.  This group has a different tone than the parent group because the dynamics are different spouse to spouse versus parent to child.  This group has operated for 2 years and average attendance is 20 people.

Finally, we have just added an off-site Family Recovery Group in our neighboring town of Spartanburg SC.  Many people from Spartanburg had been making the trip to Greenville.  However, it became clear that the community needed a satellite group.  We launched this group in 2016 by forming a partnership with a local church.  We rent the space and facilitate essentially the same group.  Average attendance at that group has been 30 people.

We also have a children’s program for children of parents in recovery and/or children of parents struggling with active substance use disorder.  This is a curriculum based program and we run it periodically based on community response/need.  We have had 103 children complete this program.  Along those same lines we have added two teen recovery groups serving teens in any stage of the process from prevention to recovery.  We have had 127 teens attend our groups.

Another distinct area of family recovery support at FAVOR Greenville is our family recovery coaching.  These are parent to parent; spouse to spouse; family to family coaching relationships put in place to supplement the various groups provided at FAVOR Greenville.  We actively recruited family members who had been “working a recovery program” and developed a specific curriculum to supplement our regular coach academy.  These family members completed a specialized training academy to become FAVOR Family Recovery Coaches.  To date we have trained 53 family coaches and currently have 29 active Family Recovery Coaches who volunteer on average 5 hours per week to coach and support other families.  We have been over-joyed with the Family Recovery Coaching programming.  We have provided over 8,000 hours of family recovery coaching since initiating the program.  The family coaches are incredibly enthusiastic and grateful and this is reflected in the way they engage our families in need.  This has been magical to watch.

Overall, it is important to note, 48% of the service hours delivered at FAVOR Greenville are delivered to family members in need.  The distinct difference with our program is the following:  Family recovery is not an add on or adjunct to service; family recovery is front and center and a cornerstone of the center.  We have found that family members want to be included in the process and they make great volunteers and supporters.  FAVOR Greenville will continue to place formal emphasis on family recovery and we believe our program will expand in the area of family recovery as we move forward in our mission.

What have we learned in our work with families?

• Parental experience in dealing with addiction is 100% different than spousal experience. This cannot be over-stated.  It is important for family programs to provide specialized services and information for parents.  We must maintain an awareness of the influence Alanon has on traditional family work.  Alanon sprung up as a support group for spouses of those in Alcoholics Anonymous and many of those principles do not translate smoothly to parents.  It is a completely different experience for parents as they struggle with setting boundaries and reducing enabling behaviors.   It is not a simple set of instructions and the conversation must be delivered in a way that is acceptable to the parent.  For example, do not tell a parent “you are sick and just need to take care of yourself”.  The result of such a statement will be complete disengagement.  This is a reality that must be acknowledged and accounted for.  We must become more individualized and engaging in our work with families.

 

• Families can become skilled in responding to addiction. It is possible to teach family members basic skills that can be useful in responding to their loved one’s addiction.  We can help them develop basic recovery messaging.  We can help them be strategic about when and how to bring up crucial conversations.  It is even possible to teach basic motivational interviewing principles and skills.  Families love information and they are empowered when they feel more competent.  I am not saying that a family member can serve as a loved one’s counselor.  However, he or she may be able to provide really helpful and tangible support.  The idea of complete detachment and “staying out of it” is looking less and less appropriate the more I work with families.  It has been said that 1 family member wields the power of 8 professionals.  Let’s teach families ways to capitalize on that power.

 

• Families can help families. Family coaching is a real discipline.  We have been training family coaches for 3 years now and there is nothing more powerful than a family to family supportive relationship.  The practical shared experience and the exceptionally strong sense of empathy is beyond comparison.  It is one of the most therapeutic supports available for family members in need.  We need more family coaches and we need to honor family recovery professionals.

 

Despite this progress we know that we have not even scratched the surface of what can be done with families.  The reality is family members have to be front and center in this fight against addiction.  It is not sufficient to merely state “addiction is a family disease”.  We have to do programming that reflects a belief in addiction as a family disease.

Recoveryism is a term used to describe an unfortunate attitude that pervades much of the addiction treatment and recovery world.  This attitude crosses all modalities of recovery and is present within many prestigious treatment organizations.  The attitude is one of superiority in regards to one’s individual recovery.  People engaging in recoveryism hold tight to the view that there is a right way to approach recovery.  Of course these people believe their way is the correct pathway to recovery.  William White defined recoveryism in the following way:

“In 2006, Tom Horvath, President of SMART Recovery, penned a brief article in which he coined the term recoveryism.  He used the term to depict assertions that a particular approach to addiction recovery was superior to all others – that there really is only ONE effective approach to addiction recovery.  Horvath rightly called our attention to a special form of bigotry sometimes exhibited by people who are grateful for their own brand of recovery.  There are those in secular, spiritual, and religious pathways of recovery who have claimed ultimate eminence for their particular ideas and methods and viewed alternatives as inherently inferior.  Radical abstentionists and radical medicationists continue acrimonious debates marked by more heat than illumination.  Those who enter recovery with and without specialized addiction treatment have each claimed a form of superiority, as have those who maintain recovery with and without participation in recovery mutual aid groups.  Each of these approaches is in turn subject to internal dissension about how that approach should best be pursued”.  (White, 2013)

Of course, recoveryism involves 12-step versus alternative pathways.  However, it also involves 12-step versus 12-step.  For example, some in the AA fellowship will challenge the validity of the NA fellowship and vice versa.  It can even go deeper.  Many times, people will disparage different home groups.  We do it the right way at “our group” and they don’t do it right at the “other group” is a position held by some.  It is even possible for dissension to arise within a home group regarding the “right way” to do recovery.  The same can be said for those attached to a “clinical” solution.  These individuals emphasize a specific therapeutic method to the exclusion of all others.  As White says above, medication assisted treatment advocates can sometimes become married to the medication only solution. 

Despite these assertions, we know the facts.  Recovery takes on many forms.  There are multiple pathways to recovery and there are millions in recovery.

Rather than taking a “my recovery is better than yours” approach, perhaps a better approach would include a focus on the common factors of recovery.  What if we shifted the question from: What is the best pathway? To What is common across many of the pathways?

The more actively one engages in these various components of recovery, the more likely recovery becomes.  This does not mean recovery will not happen with the absence of any given factor.

Common Factors:

• Recovery works best when addiction is in remission. Stating the obvious.  It is very hard to find recovery if you are actively abusing drugs or alcohol.  However, you can certainly initiate the recovery process while still using.  Many people need time to “figure it out” and we recommend that people “keep coming back” no matter what.  This includes active use.  But for the record, recovery works best when you “put it down”.

• Change in lifestyle and minimizing environmental triggers. Most people who make a substantial change in using behavior also make a substantial change in people, places and things.  You must trade in your old life for something new.  It is very hard to stop a behavior if you continuously expose yourself to temptations and reminders related to that behavior.

• The curative factors of the group experience. Irvin Yalom articulated best what happens in group therapy.  Group is a unique place.  Group gives participants an opportunity to hear from a wide variety of people and tap into some of Yalom’s curative factors:
  • Universality: you realize you are not alone.
  • Instillation of Hope: you can look around the room and see people who have overcome.
  • Interpersonal Learning/Socialization: you can get tips and pointers on how to do life from group members.
  • Altruism: you have an opportunity to help another person. That is invaluable.

• One-on-one with an “expert”. Group is very important but we also believe that a one-on-one relationship is very important.  Furthermore, we believe this individual contact should be with an expert in recovery.  Preferably someone in recovery.  However, I will go on the record.  I have known people who found recovery primarily through a therapist or a clinician who was not in recovery.  One-on-one is important because it allows for in-depth exploration of issues.  You can receive more attention and focus individually.  In addition, there are some things that you just don’t want to discuss at the group level.

• Pursuit of continuous self-improvement. People in recovery tend to focus on self-

  

  improvement and happiness.  However, the pathways of self-improvement are highly variable.  Some focus on exercise and physical health initially.  Many use the 12-step program.  Some work diligently in therapy and life-coaching.  There are many who go back to school and pursue their work dreams.  There is also an emphasis on reconciling relationships and healing.  Some do all of the above.  Whatever the details we know; the escalator is going up or going down.  Staying put is not an option.

• Filling the void. The obvious thought that comes to mind here is the spiritual component of recovery and certainly spiritual pursuits meet the criteria for filling the void.  Again, the facts are there is no one way to work on these spiritual matters.  The idea that one person can dictate spiritual experiences to another person is fundamentally non-spiritual.  I would encourage a broader look at the issue of filling the void.  Victor Frankl in Man’s Search for Meaning summed it up very well when he said: “When a person can’t find a deep sense of meaning they distract themselves with pleasure”.  And on addiction Frankl said: “Addiction is the result of living a life without personal meaning”.  For Frankl finding meaning came in a wide variety of forms and we would agree with him.

• Keep coming back. Finally, and most importantly, never give up.  If you keep showing up for therapy, recovery meetings, individual meetings you will find recovery.  It is available to all of us.