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Much has been written recently on addition driven mainly by the media storm around the “opioid epidemic”.  There are articles in mainstream press and the attention has brought this issue out of the shadows.  The debate has escalated around the etiology of addiction.  There are competing camps popping up related to the most accurate label for addiction.  These are important discussions.  Understanding the issue is central to society’s response.  Our outlook on any given problem will guide our response to that problem.  At a global level, outside of those professionally or personally touched by addiction, the moral model remains our default explanation for addictive behavior.  The moral model holds that addiction is essentially bad behavior and the individual needs to use willpower to make better decisions.  Public opinion polls show 44% to 63% of Americans view addiction this way (CASA, 2011).  If you believe in the moral model you believe addicts should be locked up.  Clearly America sees addiction as a moral issue.  Incarceration remains the preferred systemic response.  However, it is obvious that addiction goes way beyond “bad people doing bad things”.

In direct contrast to the moral model, the disease model states that addiction is a brain disease.  A complex neurobiological process in which the regulation of key transmitters (dopamine) becomes dysfunctional.  This, along with the over-stimulation of the naturally occurring craving mechanism glutamate, leads to substance use despite clear consequences, substance seeking behaviors and the overwhelming pre-occupation or mental obsession associated with addiction.  The American Society for Addiction Medicine (ASAM) describes addiction as follows:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.  Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.  This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. 

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships and a dysfunctional emotional response.  Like other chronic diseases, addiction often involves cycles of relapse and remission.  Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

If you agree with the disease model you, theoretical, believe that addiction should be treated as a medical issue.  This would imply that addiction is addressed within the bounds of our healthcare system.  Addiction would be viewed the same as any other disease.  A doctor would assess, diagnosis and refer for treatment.  Hospitals would provide care.  However, America find itself in the middle of a strange paradox.  On one hand, we proclaim the disease model and on the other we refuse to treat it within the healthcare system.  The divide between general healthcare and addiction treatment creates confusion. The implication is that people with substance use disorders are a special group that need to be isolated from general healthcare and reprogrammed.  The facts are (despite the reality that more than 2/3 of people with addiction were in contact with medical personnel the past year) most physicians and health professionals do not identify or diagnose the disease or know what to do if the issue is uncovered (CASA, 2012).  I therefore contend that the disease concept is a feel-good term serving merely as window dressing for a society that is frightened to look addiction in the eye.  We prefer to keep it locked in a closet and out of sight out of mind.  Bringing addiction into the healthcare system would improve results but require major shift in policy, reimbursement, and turf.  The status quo would be upended.

There is one area of exception as it relates to healthcare integration.  It is in relation to medication assisted treatment.  For example, physicians are able to become certified as prescribers of buprenorphine.  They can then provide medication to address opioid dependence.  This is an area that is going to receive more attention moving forward.  Regulations have been changed to support more patient engagement.  Doctors can now serve up to 275 patients instead of maximum of 100.  In addition, funding is changing.  Subsidies are coming to support those who cannot afford medication assisted treatment.  Insurance companies are liberally reimbursing suboxone treatment in parts of the country.  Surely this will expand all corners of the nation.

Maia Salvitz’s Unbroken Brain challenges the conventional disease model.  However, hers is not a return to the shaming and blaming moral model.  Instead Salvitz holds that addiction is closer to a learning disorder than a degenerative disease.  Salvitz’s position is that those of us who became addicted did so because of misfiring cause and effect system in the brain.  Our neurotransmitters become confused and we are unable to prioritize or make rational decisions where the substance is concerned.  I will not go into great detail and would encourage you to read Salvitz’s Unbroken Brain.  However, I view her interpretation as merely a reframing of the neurobiological disease model.  Both concern the same parts of the brain and both acknowledge fundamental change in processing that occurs in the brain.

The significance of Slavitz’s position is not so much etiological insight.  The significance is the potential impact this viewpoint has on treatment response and recovery services.  The most obvious implication: if it is a learning issue then the person can potential unlearn the behavior.  Furthermore, Slavitz’s position opens the door for an expansion of new approaches to addressing addiction.  A person with addiction does not necessarily require the old paradigm of treatment plus 12-step recovery meetings.  There are other pathways to recovery.  Professional providers can support creative solutions including harm reduction oriented interventions.  Medication assisted treatment also is held in high regard in this model and seen as an under-utilized intervention.  Salvitz uses an analogy of ADHD in some of her work.  She talks about how medication is effective in addressing this issue and allowing the individual to more fully engage in the learning experience.  In a similar way medication could be used to support recovery.

However, there is a dilemma that springs from this perspective, it seems logical that addiction as a learning issue eliminates addiction as a healthcare issue.  It can’t be both.  What are the practice implications if addiction moves further away, in terms of semantics, from the disease model?  Slavitz’s position is unlikely to gain traction due to the firmly entrenched “theoretical disease model” that exists in the treatment industry today.  It is very unlikely that anyone will take her seriously on a mass scale.  If open-mindedness did exist and this view was given serious consideration reconciliation with healthcare would prove difficult.

Another model that has received a great deal of attention is Johann Hari’s addiction versus connection theory famously presented through his 2015 TED talk entitled “Everything You Know About Addiction Is Wrong”.  The short story version of Hari’s work is the following: Rat park was an infamous study where scientists got some rats strung out on cocaine resulting in a group of rats who refused to eat, have sex, reproduce or do anything other than cocaine.  They then get some other rats strung out but create opportunity for connection with other rats and create a “park” where these critters can frolic about.  This second group chooses to eat, drink, reproduce rather than use cocaine.

The conclusion was connection mitigates the effects of addiction.  Hari also talks about the phenomena of apparent transformational change that occurred with Vietnam vets and heroin addiction.  It seems that the overwhelming majority of Vietnam vets stopped using heroin upon their return to the states.  Again, this was attributed to the connection that occurred back in their native country.  Of course, the talk and Hari’s thesis contains much more depth and detail.  However, the overall emphasis is on lack of connection as the problem and connection as a major part of the solution.

The practice implications of connection versus addiction are interesting.  It is a widely-held belief that recovery involves community.  Therefore, the emphasis on connection makes sense to many in the addiction treatment and recovery world.  However, over-emphasis on the connection presents a challenge to the disease model.  There have been some who criticized Hari for removing the neurobiology of the process.  Hari is quick to say that was never his intent.  At a policy level this theory could easily lead to less emphasis on integration into healthcare.  At the same time connection-theory could lead to an increase emphasis on recovery support as recovery support is all about connection.  Obviously, this appeals to me on a personal and professional level.

There are many other perspectives on addiction these are simply the most commonly held.  It is very interesting to see addiction discussed so openly.  Hari’s TED talk yielded 15 million or more views.  The danger is confusion on the part of the general public.  If we don’t have agreement on what addiction is then we will automatically default to the moral model.  That is the position people are most comfortable with and the position people are naturally drawn to.  I believe addiction is a brain issue.  Call it a disease or disorder or “brain problem”.  The “theoretical” disease model is not going anywhere soon, it is firmly entrenched.  However, it could be threatened based on two factors:

• Our societal practices do not reflect a belief in the disease model. In other words, we call it a disease but refuse to treat it within healthcare.
• Our current response, which is based in theory on the disease model, is inadequate (CASA, 2012). In other words, we have not slowed addiction down in the slightest.

This leaves us ripe for an alternative theory.  I fear it may be a doubling down on the moral model.

A very good exploration of where to find support. Negative support is worse than no support at all…

In my sociology class today we watched the Frontline documentary on heroin. I’m not sure anyone really realizes how intense the situation is with the current addiction epidemic. When you open your eyes and ears to the situation it’s stunning. I think it may be too much for most people to acknowledge. It’s a rock we really don’t want to look under.

What are the organizing principles that guide FAVOR (and other JSG Inc. projects) as we grapple with making a dent in the wall of addiction? Here you go:

We must talk about addiction and recovery openly to reduce the stigma and make help more attractive. We must PROMOTE recovery. Promote open discussion. Make recovery cool. Market recovery. If we can sell a $2 tee-shirt for $50 via creative marketing then we can do better than 10% engagement in recovery.

We must focus on engagement and retention in a helping relationship. Change takes place in the context of a relationship. The hard-ass “my way or the highway” professional approach needs to be thrown on the trash heap. Kicking people out of services should be rare. It’s wrong. It’s lazy. It’s malpractice. Keep the person engaged. If your a professional you should be held to a higher standard. Do what you want in your personal recovery. But don’t run your professional program like you run your home group. Two different things.

We must utilize and explore all pathways to recovery. Who cares how or where or why a person gets better. Just get better.

We must engage family and friends in their own recovery process in an aggressive and assertive manner. They deserve emotional support and change in the family frequently leads to change in the addicted individual.

We must start early with kids. Engage them in an age-appropriate program. Just say no is useless. Focus on the environment as a therapeutic tool. Don’t expect them to sit through psycho-educational groups. Don’t expect adult interventions to work with kids. Relationships are even more vital where kids are concerned.

We must advocate and help people find quality residential treatment when appropriate. The key differentiating factor is the ability of the facility to provide or ensure real aftercare and follow through. Think about it. Nearly every program has a psychiatrist, psychologist, licensed counselors, 12 step emphasis, groups, individual, yoga, executive chef, acupuncture etc…All good stuff but literally all the same. So for us the one difference is “can you do aftercare”.

We must push the integration of technology in order to scale services. Thinking in terms of hundreds of thousands new customers per year. The more people who hear the message the better. It’s not easy but it’s possible. If we could bring hundreds of thousands into a recovery conversation. And the community will reach a tipping point. It will become routine to reach out for help.

We need to bring outsiders (business people, those not in recovery or treatment industry) into consultation around solving this problem. Closed industry conferences and meetings where people all preach the message to an already converted choir will yield little creativity.

We need to work tirelessly to get this done and we need to compensate staff accordingly to keep good people in the fight.

The goal is 90% of people needing help will be engaged in help rather than only 10%. In Greenville that’s 36,000 people in addiction getting help rather than 4,000. And another 200,000 family members. In AMERICA that’s 22 million people getting help rather than 2.4 million. That’s the way it should be. A dent in the universe.

It’s worth it. It’s winnable. It’s possible

Recovery Coaching Freud: A Motivational Interviewing Approach

Freud. I would have enjoyed being his recovery coach & helping him overcome his addiction to cocaine.

I would start with. Mr Freud tell me more about your cocaine use? He responds “it helps me write. not a problem”.

Leaning on my old school training and using a traditional approach I respond. “That’s your denial system you need to admit you are a garden variety addict and go to rehab”.

Not surprisingly Mr Freud becomes defensive and launches into a dissertation on defense mechanisms Given the fact he invented the concept of denial he renders me useless. He continues the Jedi mind trick. Steals my car keys and goes on epic crack run. I have ruined Freud.

His second session I use a motivational interviewing approach. I open. “Mr Freud tell me more about your cocaine use”

He responds. “I really don’t think it’s a problem. I use it to help me write”.

In classic motivational style I reflect back. “So. It makes writing easier”. Sigmund says- “yes I get more done”. Therapeutic rapport is established.

I affirm him. “Thank you for being so open. This is a tough topic”. He seems to warming to the relationship.

I move to highlight dissonance “tell me about any times when cocaine may have hurt your work performance”.

Sigmund relates a story of how he stayed up for 13 days on cocaine and in the middle of a drug induced psychosis formulated some strange theory that involves subconscious sexual attraction of children toward opposite sex parents. Sigmund says “that was some crazy shit. I’ve always regretted writing that. Now everyone thinks it true”…

I highlight change talk stating. “Maybe you should get some help so you don’t destroy mankind any further and spend eternity in hell”…

Sigmund reluctantly agrees…”maybe you’re right. I will go to rehab”.

So we spend the next 3 days calling facilities and no one will take his insurance. Eventually we find a faith based program that he can afford but they have a waiting list and by then Sigmund changes his mind. Fortunately we believe in multiple pathways and put together a plan of group therapy, FAVOR GREENVILLE support groups and hot yoga. Sigmund lives happily ever after.

 

Chapter 2: RECOVERY COACHING FREUD—The Recovery Plan
Mr. Freud jumped into his recovery plan full force. He attended a meeting everyday, continued his coaching with me and even secured a sponsor. His effort and involvement at HOT YOGA was described by the instructor Mr. Carl Jung as being “truly inspired as if Sigmund is the archetype of the downward dog”. Clearly I was the greatest recovery coach in the world.

However, as time progressed something strange started to happen. Mr. Freud got a job at Hot Topic at the Mall and had to work “strange hours” that cut into his meeting attendance. He also missed a couple of coaching sessions. A couple weeks went by and Sigmund just disappeared. A few random phone calls to Sigmund were not returned. It was apparent that Sigmund had disengaged from recovery. A little voice in my head told me it was not my fault. If Mr. Freud didn’t want recovery it was his fault. But my rational voice came in and said…”what could I have done different. Why do we blame the patient when the service doesn’t work”?.

The little voice in my head came back at me: “Rich…Sigmund is just taking his own will back and this demonstrates that he is not fully surrendered. He needs to go back out there and experience some more pain. Just sit back and wait until he really wants help. You can’t help the unwilling.”

But my logical and rational voice said: “Dude call his mom and see if she has seen him. See if you can do some outreach to bring him back into recovery. Yeah some people will call that professional enabling but those people will be obsolete in short order and who gives a shit what they think”.

So I called his mom. She was really hard to understand due to a thick Austrian accent. But after some time I realized that Sigmund was sleeping on her couch, refusing to pay rent, and eating all her food. Mom said she wasn’t sure what to do. I ask her “do you have anyone who could help us with an intervention”. She said she would ask his friends: Dr. Maslow, Dr. Frankl, and M.C. Hammer. She said his younger brother would “help out too if I can get him off the weed for a day”.

We met at Coffee Underground for the intervention preparation. I tried to review the basics of addiction and recovery but Dr. Maslow kept rambling on about self-actualization and heirarchy of needs while Dr. Frankl waxed poetic about making meaning out of suffering. Mr. Hammer kept telling me I couldn’t touch this and Freud’s brother was good and blazed. They struggled mightily with developing a recovery message that came from a place of love. They said things like “all addicts are liars and manipulative and you have to be tough. No love”. It was a difficult preparation. But eventually we got everyone involved to agree to a loving and kind recovery message. We scheduled the intervention for the upcoming Monday night after family group. We would meet at the FAVOR Greenville Recovery Community Center…I was anxious…
Stay tuned for…The Intervention…

Chapter 3: Recovery Coaching Freud: THE INTERVENTION
The intervention was scheduled for Tuesday but by Saturday afternoon I was already receiving frantic phone calls from Sigmund’s beloved mother. She was upset because Sigmund had been missing for nearly 2 days and he must have turned off the GPS tracking device she had hidden in his car. I reassured her the intervention would help and ask her if she had been talking to her family recovery coach.

She responded rather tersely: “I’m not the one with the problem Sigmund is. I don’t need a coach I need someone to fix my boy.”

I took a deep breath and redirected her with the utmost care. I wanted to be gentle given the fact that family recovery is difficult and given the fact that she was 175 years old. “Well Mrs. Freud you agreed that you would work on your own recovery program in support of Sigmund. Have you checked-out any Alanon meetings?”

She said she did and “everyone was nice” but I am not at all interested in working steps and plus Wheel of Fortune comes on at 7 pm and “there is no way I’m missing that. Pat Sajak is a hottie”. I encouraged here to attend the FAVOR Monday night family group and she agreed. She had heard wonderful things about the facilitator of that group. People in that group had described the facilitator as genius, gifted, amazing and the world’s most interesting man. Finally we were able to discuss the other participants.

She told me all the key players would be there except for Sigmund’s father who had been killed by Sigmund already consistent with normal pre-adolescent development (anyone get that?). So all that was left was to wait until showtime on Tuesday afternoon.

Tuesday came and we all gathered at the FAVOR center. Dr. Skinner was sure that Sigmund would not show because the appropriate mix of negative and positive reinforcement had not been struck. I assured him that he would show and told him the ARISE intervention method I had been trained in was evidenced based. He responded…”What the hell does evidenced based mean…We do what ever the hell we want and the only evidence we need is “that sounds pretty legit”.

Dr. Frankl kept muttering something about making meaning out the “apparent suffering”. A new addition to the group, Dr. Pavlov spent all his time tending to his dogs. Which was really weird. I was sure all these dudes were high but decided to proceed with the intervention anyway. My goal was to get Sigmund into treatment.

As instructed, Sigmund sat quietly while his friends and family made heartfelt pleas for him to seek help. It was truly inspirational the way the intervention network came together. They stayed on point and spoke from a place of love and genuine concern. Now it was time for Sigmund’s response.

He stared at us with what could be described as an IRON GAZE. He lit into the crowd trying to justify and minimize his behavior. “Everyone smokes crack when they are trying to develop a comprehensive explanation for human behavior”. We stood firm. He called people out one by one… “Skinner you smoke weed with pigeons and Pavlov you and those dogs freak me the hell out”.

Finally, he turned his attention to me. “And you. You call yourself a therapist. You are one stupid shit and you have no idea what is best for me. I wrote the book on therapy (couldn’t argue with that one) and you couldn’t therapize your way out of a wet paper bag. Plus you head is too large for your body and I can’t stand the way you chew gum with your mouth open”. Sigmund was trying to lure us into a confrontation. He wanted this to degenerated into an A & E made for TV special. I was unfazed. I had been here before. I stood firm.

“Sigmund…The point is everyone on this team cares about you. You can refuse treatment. But we will all continue to meet to work together to get you help. And we will not go away. We are going to stay on you until this gets better”.

Sigmund began to tear up. He then broke into an ugly cry like I have never seen before. SNOT flying everywhere. He kept yelling things about the ID and the EGO and all this weird shit about being in love with his mother. But in the end he agreed to go.

Fortunately we had hired a “sober transport” company to get him to a very special rehab located in California. We were sure this program would do the job. The website touted the facility as a premium program (but so did every other one we looked at) but the real differentiating factor was their use of Acupuncture (oh wait all the others did that too) and Equine Therapy (wait..darn it they all do that too). Actually we picked California because it was so far away making it less likely he would leave AMA.

We crossed our fingers as we watched the sober transport drive away. I thought to myself… “Holy shit… I just sent Freud to rehab!”

Chapter 4: Recovery Coaching Freud–The Rehab Experience
To say that Sigmund’s rehab experience was difficult is a massive understatement. That is like saying the Titanic was a small boat accident. It all started when he landed in California and got settled at the posh Malibu Do As We Say Or Die (DAWS or Die) Center for Recovery and Spiritual Awakening. We had utilized a national recovery hotline (1-800-we-rob-addicts) to secure the referral and they assured us that his insurance would cover the stay. The referral call was odd as I noticed a distinct Indian accent on the part of “admission consultant”. I questioned if this was “a call center in India” and “Jack” reassured me that he was in fact an official representative of Malibu Do As We Say Recovery Center.

Well… after about 3 days in treatment Sigmund’s mother received a call from Malibu DAWS or Die. The staff reported that Sigmund had been adjusting well and that he seemed ready to make a change. They felt he was finally ready for lifelong sobriety. They could clearly tell this because they are geniuses and he had been there for a whole 72 hours. However, they were sorry to say his insurance had been denied and that Mama Freud would need to remit full payment of $1,764,123.87 by midnight or he would get “dropped off at the local Costco” (they had determined that was the safest place for administrative discharges).

Mama Freud called me in a full fledged panic. She clearly did not have that kind of money. She thought about tapping into her 401k or maybe taking a loan. The rehab had told her that they offered loans at 125.8% interest. Mama Freud was between a rock and a hard place. We decided to consult with a friend in California to seek out alternative placement. We contacted a local recovery center to see if they could help us navigate the system. They hooked us up with a really great guy. Mr. Garcia was somewhat spacey but very helpful stating “man I’ve been to every rehab in California”. He was able to locate a free faith based program staffed by recovering Dead-Heads. Apparently this place had “the cure”. It was called Passages Malibu Sugar Magnolia campus.

Sigmund had a rough landing at Passages Sugar Magnolia. He was chronically late for morning meditation and yoga and had a very contentious relationship with his primary therapist. Apparently the therapist kept saying that Sigmund’s problem was his EGO to which Sigmund replied “That’s the biggest crock of shit I ever heard. If my EGO were not in tact I would be a floundering piece of whale dung”.

The therapist then replied. I have been doing this work for 3 years and I’ve been in recovery for 20 years. Your job is to listen and follow directions. You don’t know anything….”

To which Sigmund replied: “I invented the concept of EGO”….

To which the therapist responded: “Yeah in the middle a cocaine induced hedonistic marathon..”

To which Sigmund replied: “Yeah… Good point”…

Boom… Therapeutic breakthrough. From that point forward Sigmund was a model patient. Yes he complained frequently about the kale salads and he struggled because “all these staff smell like patchouli oil; but overall he was a treatment superstar. He was named CHIEF of the men’s primary unit and his “graduation” ceremony was truly heart-warming. He was able to complete the program and he arrived back in Greenville South Carolina with 35 days sober and a new improved attitude.
Stay Tuned for Chapter 5: The AFTER-CARE PLAN…

 

Recovery Coaching Freud: The Aftercare Plan
I was somewhat nervous as I anticipated my coaching session with Signmund. This was our initial meeting following his inpatient stay at the Promise Sugar Magnolia campus. I had heard nothing from any of the counselors at Promises SM and had no idea what the aftercare plan was for Sigmund. I was used to this as it had essentially become the industry standard to not communicate with me as a community based provider despite the fact that I refer 10 to 15 people to private facilities each month (sorry). I had no idea what the recommendation for aftercare was or if Sigmund had agreed to any specific recovery plan.

“Where’s a copy of your aftercare plan?” I uttered.

“My aftercare plan? What the hell does that mean” Sigmund shot back

I was completely aghast and stunned despite the frequency with which this occurs (sorry). “You should have an aftercare plan for recovery that we can help you implement. Usually it involves meetings and probably some type of intensive outpatient program. Did they refer you anywhere?”

Sigmund seemed confused but stated: “You mean that thing we did when my mom came to family week?”

“Yes probably”… “Did you get a copy of that”. My exasperation was clearly evident.

Sigmund laughed. He was amused by my disbelief. “No man I threw that shit away. But it’s not hard to remember the plan. They told me to go to the local clinic for psychiatric follow-up (Passages SM is a co-occurring facility THANK GOD) and to do 90 meetings in 90 days. But I can’t remember the appointment date for my follow-up and I am not doing any 90 meetings in 90 days”.

I was completely incredulous: “Why did you agree to 90 meetings in 90 days if you had no intention of doing them?”

Sigmund smiled: “Because you get in trouble if you don’t agree to do 90 meetings in 90 days. I figured out what to say and what not to say early on in that place. Hell I don’t even think I’m an addict but I sure as hell wasn’t going to tell anyone that. There was some dude named Ozzy there who said he was going to quit heroin but still smoke weed. They put him in the “special re-education” group and he is still there. I got out early “for good behavior”. His mom was so upset. The rehab called Ozzy non-compliant and in denial”.

Wow. Now here was a dilemma. This guy just completed inpatient rehab but was already planning to smoke weed. Sigmund was sure he was never going to do crack cocaine again but stated: “marijuana is not a drug and no one ever over-dosed on marijuana”. I called Passages SM and tried to get clarification. The intake person would not direct me to Sigmund’s primary counselor and suggested we put him back on a plane for “another round of inpatient. Or better yet”, the staff member said, “let him go out and get high and hit bottom then he will come back and be ready to follow directions”.

I said “bottom for Freud probably means death. And he still has some really weird theories to develop.”

My well-intentioned friend responded: “Well some of us have to die…so others of us can live”…

I went into what could only be described as a epic twerking type fit of rage. My body gyrated uncontrollably and I strung together cuss words which were never intended to run together. I couldn’t believe a treatment professional would utter such words. I don’t know why it struck me so hard. I had heard similar things before. Perhaps it was because these people were working hard to kill off the father of psychotherapy or maybe everyone has a breaking point. But something inside me snapped. Fortunately Mike Tyson was standing by to give me a swift punch in the mid section to bring me back down to earth. I immediately utilized my HOT YOGA skills to calm myself….

As Sigmund looked cheerfully on I couldn’t help but think: “Holy shit….we have killed Freud…”

Stay Tuned for Chapter 6: “Freud Gets Ninja Recovery”

TO BE CONTINUED….

 

This is a recycled post. However, I believe it offers a very interesting perspective on the current state of affairs in our country.

Introduction:

FAVOR Greenville is a Recovery Community Organization (RCO) which provides a unique and innovative answer to the baffling problem of addiction.  Founded in 2004 FAVOR Greenville has grown from a grassroots education and advocacy program into a service deliver organization serving more than 6,000 individuals in Greenville and the surrounding areas.  We opened a Recovery Community Center in 2012 and provide individual and group recovery services for both those seeking recovery and their families.  In addition, we offer intervention services and socialization opportunities for families and individuals of all ages.  We have added a prevention component as well with a group dedicated to children age 9 to 13 and another focusing on teens age 14 to 18.

The Problem–98% of People with Addiction DON’T WANT HELP:

There is much debate related to which treatment works best for people in need of recovery.  However, we are of the opinion that this debate is largely a waste of time.  We know that people recover when they seek help.  There is no one size fits all answer and there are multiple pathways.  The odds are relatively good that you will find permanent recovery (around 2/3) if you “keep trying”.

The problem is we have failed to address one major symptom of addiction: people DO NOT WANT HELP.  They are in denial or resistant or whatever label you prefer.  Regardless of how you frame it up the reality is 95.5% of “people needing treatment but not getting help” did not feel that they needed help.  It’s been that way for decades.  Source: NHSDUH, 2013

There is general agreement that “denial” is a part of addiction yet we are unwilling to find creative ways to engage the 95.5%.  The traditional viewpoint is that we should sit back and wait until the individual “hits bottom” or, in some cases, initiate an intervention.  Whatever we are doing, it is not working.  If you include the 2.9% who recognized need but did not make effort the total is 98.4% of those in need that are left unattended to.

Essentially, we have been aiming at the wrong target.  The question should not be “How do we best help the willing”?  Instead the question should be “How do we connect with the unwilling”?   Until we find a solution to the staggering statistics mentioned above all our efforts at confronting addiction will be largely ineffective.

Young People:

The picture is even more revealing when you examine the information related to young people and recovery (NHSDUH, 2013):

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 Solution:

FAVOR Greenville Youth Empowerment Services Presents:

The A.C.E. program at FAVOR GREENVILLE (Assertive Community Engagement)

FAVOR Greenville has launched the Assertive Community Engagement (A.C.E.) program with a focus on engaging and retaining individuals in recovery.  Our interest is in the 98% of individuals who do not believe they need help and/or did not attempt to access help.  We think that this percentage can be substantially reduced through creative engagement such as home visits, parental engagement, community visits, use of technology, and a commitment to evidenced based coaching techniques which promote establishment of therapeutic rapport.

In addition, due to the above mentioned vulnerabilities and historically poor results associated with youth and young adults, the A.C.E. program will initiate services with a focus on young people.  A.C.E. will be part of our “Youth Empowerment Program” service line.

Criteria for Involvement:

• Focus on 16 to 26 year olds experiencing substance abuse or dependency.
• Family needs to be Greenville County/surrounding area resident but the “client” does not necessarily need to be in Greenville at the time of service engagement (ie…young person “off” at college).
• Family or other interested party can “make the referral”. All we ask is that the family inform the individual they will be contacted by FAVOR.  C.E. staff will initiate the relationship from that point on.  We do not need the client to show up for session.  We will figure it out.
• There needs to be some evidence of resistance to traditional avenues of help (ie…the young person refuses to attend outpatient counseling or meetings or group therapy etc…)
• The parents/family need to be open to home visits and willing to participate in family meetings and other family recovery related activities.

Overview of the program:

In some states Mental Health has a long tradition of delivering services in the home and/or community (ie… Targeted Case Management, Intensive Case Management, Assertive Community Treatment).  These programs have been exceptionally effective at engaging patients, reducing healthcare costs across the board, and supporting improved quality of life among participants.  Borrowing on these principles the A.C.E. program will provide direct services in the home and community.  These principles include:

• Motivational Interviewing as the foundation for all coaching activities.
• Peer-based recovery coaching as the primary vehicle for engagement.
• Integration of natural family and other social supports into the recovery planning process.
• Regularly scheduled in-home visits and phone calls/texts to support connection between visits.
• Small caseloads to ensure appropriate staff response.
• Specially trained staff dedicated to the A.C.E. program.
• Case-management and service coordination interventions as needed/appropriate.
• Strengths-based and solution focused interventions.
• The “environment” as a therapeutic tool.

We believe that a focus on engagement will result in 20%-30% increase in recovery retention.  We believe that people in the “recovery process” improve regardless of number of “days clean”.   It is the HOPE of FAVOR Greenville that this type of program will serve as a model for realistic, cost effective and efficient recovery outreach.

for more information please see FAVOR Greenville

 

 

Conflict Management applies to all areas of our lives.  The workplace requires effective conflict management to ensure productive relationships.  Conflict in the workplace includes:

• colleague to colleague
• employee to supervisor
• internal (company) to external (customer)
• interdepartmental (between business units)
• management (as a whole) to worker (union)

In our personal lives the potential for conflict seems like it is infinite.  Examples include:

• Parent to child
• sibling to sibling
• friend to friend
• And, of course, spouse to spouse

Relationships are full of ups and downs.  The potential for disagreement is ever-present.  If we can learn to negotiate conflict we will experience improved productivity, happier relationships and much less stress in our lives.  I would like to offer the following principles as a guideline for managing conflict.

1. Conflict Management really comes down to crucial conversations: Managing conflict at its core is about being willing to have crucial conversations.  Most people struggle with identifying and initiating these crucial conversations.  The first principle is IDENTIFICATION of these conversations.  Crucial conversations contain the following elements:
   1. There is a difference of opinion: this is an obvious element. If the parties involved are “in agreement” then the issue is settled.
   2. The stakes are high: if the matter is insignificant and petty then the difficulty of the conversation is also insignificant. In crucial conversations the stakes are very high.  For example, money issues/contracts in business; differences in parenting approaches among spouses; contrasting opinions on business plans between partners.
   3. Emotions run high: it is easy to see how emotions can ramp up in the midst of these difficult conversations. It is very easy for people to act out in anger and frustration during a serious and important discussion.
2. There are 3 ways to handle crucial conversations:
   1. Avoid the conversation: this is probably most common. The parties involved unconsciously (or consciously) avoid confronting the important issues.  The idea of having a difficult and potentially contentious conversation is too much to handle.  There is a tendency to make excuses and hope for the best.  The problem with this approach is obvious.  The unspoken issues are going to break through at some point.  All too often the result is an overly aggressive outburst when the individual “can’t take it anymore”.  In addition, these unspoken issues create underlying stress that can be detrimental in its own right.
   2. Have the conversation and handle it poorly: this is frequently the result of the above mentioned avoidant behavior. However, poorly handled conversations can also occur even when issues are immediately addressed.  Poorly handled conversations are laden with anger and anxiety.  Relationships can be permanently damaged when these conversations are butchered.
   3. Have the conversation and handle it well: it is possible to have a crucial conversation that results in positive outcome for all involved.
3. When entering into a crucial conversation be sure you have a clear understanding of your desired outcome. This will guide the course of the conversation.  You need to be rational and objective about the intended outcome.  Many times people have objectives that are less than productive.  These thoughts are usually operating at a subconscious level and the individual is not overtly aware of their own operating system.  Self-awareness is essential to managing conflict.  We need to be 100% honest in terms of our intended outcomes.  Examples of problematic desired outcomes include:
   1. To put someone in their place.
   2. To get “my own way”.
   3. To win the argument.

4. In a similar vein we are more likely to productively manage conflict if we have a general awareness of our own shortcomings and “buttons”. We need to exercise good social judgement and assess our areas of strength and our areas of weakness.  Are we easily frustrated by certain subject areas?  Do we have a history of conflict with the others involved?  Do we struggle with authority?  Are we fearful of how our teenager will respond to the conversation?   These stories are running through our mind and greatly influence the way we interact with the world.  If we become aware of our personal triggers we are more likely to manage our emotions effectively.  Essentially we need to minimize our “blind spot” in order to negotiate these high emotion interactions.
5. Finally, we need to approach crucial conversations from a WIN-WIN perspective. We should ask ourselves the following question:  How can both parties gain from the interaction?  This will require an intentional effort on our part.  Our default setting is to try to advance our own cause and “win” the negotiation.  But remember, a crucial conversation is not a negotiation.  Instead, a crucial conversation is a way of maintaining and advancing a professional or personal relationship.

 

Take the opportunity to apply these principles to the next conflict that arises in your life.  We believe that the use of these principles will make a huge difference in your management of conflict which in turn will improve your life…both professionally and personally.

 

 

Robert Greene, NY Times best-selling author, expressed it well when he wrote all of life is a hologram all that we see in people is not real.  It’s not quite as wonderful as FACEBOOK would have you believe.  However, we have pulled the curtain back and we know the reality of life backstage.  People are dealing with real deal problems and emotional distress is more the rule than the exception.  There are worries about kids, worries about parents, worries about school, worries about work, and WORRIES ABOUT WORRY.  Workloads are increasing and the fact we are always connected is adding to the problem.  Technology has an interesting way of transforming life for the better and the worse simultaneously.

The good news is that if you find an appropriate perspective anxiety and stress can actually become a friend.  Both can activate us into action and if kept in proper context the damage of chronic stress is minimal.  There are many ways to effectively deal with stress and other emotional concerns.  Logic tells us that happiness trumps stress.  It is difficult for these two emotions to co-exist.  The discipline of positive psychology teaches that 5 areas contribute substantially to subjective well-being (or happiness).   The acronym PERMA is an easy way to remember the “magic” formula:

• P=Pleasure or what you do for fun, hobbies. Also the absence of pain and need.
• E=Engagement or what you do that ignites your interests. Could be work or some other endeavor.
• R=Relationships or who are the significant people in your life. Quality over quantity.
• M=Meaning or greater good. Are you connected to something greater than you?
• A=Attitude or your outlook on any given situation/event.

HAVING A CORNER-MAN CAN MAKE ALL THE DIFFERENCE:

Finding a person you can trust is essential to coping with stress, worries, anxiety and their associated problems.  You may be familiar with the concept of venting.  Venting, the way it is traditionally conceived, has been disputed by many people as an effective way to relieve pressure.  However, I am encouraging something beyond the venting process.  Venting implies one person expressing frustration while another person sits passively by just listening.  Listening is essential part of the supportive relationship but I am encouraging a more strategic and pro-active process.  We believe that a corner-man can help you address all aspects of PERMA.  This is a more effective process than merely venting:

• P=A corner-man can help identify opportunities for fun, participate along with you, and help problem solve disconcerting situations.
• E=A corner-man can help process work related issues and problem-solve other opportunities for engagement.
• R=This area is self-explanatory as a corner-man constitutes a high quality relationship.
• M=A corner-man can provide support, encouragement, and help explore this existential area of life.
• A=A corner-man can provide clarification, reframing and support as you revaluate situations and events in your life.

The term corner-man comes from boxing and signifies a very special relationship.  The corner-man is a “coach or teammate assisting the fighter during the length of a bout”.  In life’s terms this means that the corner-man is there to go through the turmoil with you and coach you through the “fight”.  Please understand that a corner-man is not an easy find.  We have identified 5 essential qualities of a corner-man.  The more of these qualities an individual has the more productive the relationship will become.

• A good corner-man is supportive, accessible and present but doesn’t solve the problem for you: In boxing the corner-man remain outside the combat area during the fight but is in close proximity to the action.  He provides assistance, advice, and instructions but doesn’t try to intervene in the action.  A corner-man in boxing waits until the opportune time to provide support, usually between rounds.  The same can be said for a corner-man in life.  If your corner-man becomes overly involved (for example engages in enabling behavior) the support can become counterproductive and problematic.  At the same time your corner-man in life needs to be accessible.  For example, if it takes two weeks to get an appointment to see a therapist you need to find a new corner-man.  You may keep your therapist, but you may want to get a corner-man.
• A good corner-man has some direct experience with the battle: In boxing a corner-man is almost always an ex-boxer, trainer, or coach.  Rarely will somewhere just come in from the sidelines without the lived experience of the sport.  The same can be said of a corner-man in life.  Your corner-man doesn’t need to have identical experience to your current struggle, however, he should have some history of over-coming something.  If he presents himself as void of past difficulties than I would run the other way.  That would be the equivalent of having me as a boxing corner-man.  Someone will get hurt real bad.  It is very much an issue of experience versus theory and we encourage you to lean heavy on the experiential end.
• A good corner-man will provide individualized support and instruction: In boxing a corner-man will vary his approach according to the individual needs and characteristics of the boxer.  A right handed boxer is not handled the same way as a left handed boxer.  A “technician” is handled differently than a “brawler”.   Rocky was handled in a different way than Apollo Creed.  The same can be said of a corner-man in life.  Unfortunately most “helpers” prefer to give rote instructions and a manual on life.  They seem to maintain an attitude of “if it worked for me and/or I read it in a book than it will certainly work for you”.  The essence of human motivation lies in the unique needs, values, and psychology of each individual person.  A one-size fits all approach is destined to yield little positive return.
• Occasionally the corner-man has to perform “cut-man” duties: In boxing there will be times when the boxer’s eyes and face will swell due to getting repeatedly punched in the face.   This can make it very hard to see the opponent.  Sometimes in these circumstances the corner-man will need to “cut” the boxer to relieve the pressure and make it possible for the boxer to see again.  Sometimes your corner-man in life will also need to say or do whatever is necessary for you to be able to see clearly.   Your vision can become cloudy by repeating a behavior over and over or by a well-defined denial system (ie…getting punched in the face repeatedly).  In these cases your corner-man in life may need to cause you temporary pain for long term gain.
• Finally, the corner-man is many times the one responsible for “throwing in the towel”: In boxing the corner-man usually holds the responsibility of throwing in the towel to signify the fight is over.   This is done when the boxer is getting beaten to a point of danger.  Throwing in the towel is usually not received well by the boxer.  The fighter will naturally want to continue the fight and go on to the bitter ends.  In life it can also be necessary to throw in the towel and get more intensive help.  The best example is a person struggling with addiction.  Sometimes the corner-man needs to pull the rip-cord and get the person off to rehab or more intensive help.

 

I noticed an interesting phenomenon recently.  At times, when I greet one of my clients at the beginning of our session and ask “How’s it going” there is an awkward silence.  It is as if they are thinking “Does he really want to know”.  Given the nature of our relationship this is not unusual.  Certainly, I want an honest answer and we will dig deeper into that question during the ensuring hour.

However, it has made me think.  How would I answer if I was 100% honest when ask the question how are you doing?  The answer would depend on the day and time of “the ask”.  Just for the heck of if let’s review one day out of my past week and take random time samples to see what an honest answer would look like:

THURSDAY 3/17/15:  6:30 AM- How are you doing?   “I’m tired and I don’t want to get up”.  My weekend is fast approaching but I wake-up pre-occupied that it will be too short.   My self-talk entails the following:  “I need to quit working every Saturday.  I’m a bad father because I spend too much time working”.  I would characterize myself as dysphoric (not depressed; just a bit “down”) at this point in time.  Been hear a million times before and know I just need to move forward.

THURSDAY 3/17/15: 7:00 AM- How are you doing? “Great… I’m on top of things”.  I’m two cups of coffee into my allotted caffeine intake and I’m going to kick ass and take names today.

THURSDAY 3/17/15: 9:00 AM- How are you doing?  “NOT GOOD”.  I forgot to correct my exams for the G-Tech class I teach and now the students are looking forlorn and sad and I feel inadequate.  I am engaging in some negative self-talk concerning my work output and use of free time this weekend.

THURSDAY 3/17/15: 9:15 AM- How are you doing?  “I’m F-ing fine”!  I tell myself “you know what I didn’t want to teach these classes anyway they can fire me for all I care.  Freedom…sweet freedom”.  Amazing how perspective changes everything.

THURSDAY 3/17/15: 10:45 AM- How are you doing? “I’m feeling overwhelmed”.   I have 7 appointments throughout the initial part of the day today (in a 4 hour period) and I’m not sure how that is going to work.  My self-talk is “Why do you do this over and over again?  You’ve been over-scheduling for 10 years.”  I recognize this pattern as well and I know that I need to move into a problem-solving mode.

THURSDAY 3/17/15:  11:30 AM- How are you doing? “Optimistic”.  I made a couple of phone calls and have re-arranged some appointments.  Also had a great phone call regarding some business opportunities.  Also have some really exciting ideas bouncing around my head.  Self-talk is non-specific but generally revolves around the concept that I am a badass.  Taking action is important for me.  I struggle with analyzing situations and would rather act.  READY-FIRE-AIM.

THURSDAY 3/17/15: 1:00 PM- How are you doing? “I feel flat”.  Nothing in particular going on.

THURSDAY 3/17/15: 3:15 PM- How are you doing? “Worried”.  My house in Pennsylvania needs a new roof.  $10,000.  Financial worries are always just below the surface with me.  Self-talk is non-specific but revolves around my lack of preparation and borders on victimhood surrounding my inability to sell the house in Pennsylvania.  I work hard to rationalize the event and reframe the situation effectively.  The worry does subside.

THURSDAY 3/17/15: 3:30 PM- How are you doing? “I’m great”.  On my way to a meeting at local TV station regarding a documentary we are going to be part of.  Self-talk involves positive reinforcement as I have been able to manage some nervousness and resistance around this event.  I won out over my mind on this occasion.

THURSDAY 3/17/15: 6:15 PM- How are you doing? “Refreshed”.  Played some pick-up basketball at the YMCA and actually resembled my old self.  Rather than the pathetic display put on at the league game last night.  Self-talk is positive.

THURSDAY 3/17/15: 8:30 PM- How are you doing?  “Tired”.  Physically tired.  When I am tired like this negative thoughts sneak in.  Usually related to the amount of time I spend working.  If I’m not careful this can lead to guilt about time lost with my kids.

THURSDAY 3/17/15: 10:00 PM- How are you doing? “Good…”  I really mean good.  It was a long productive day doing important work.  I’m in bed.

If you would have been with me and asked me at any of those times “How are you doing?” I would have given you a confident “I’m good” response.  You would have never known any of this was going on.  Right now I am grateful to report that I don’t have any major crisis in my life.  And yet, my day can be an emotional mine-field if I allow it to be.

There were times I recognized and managed my irrational thoughts and times when I fell victim to automatic thinking and the associated negative feelings.  There were really good things that happened and some not so good things.  There were situations I created and situations that were created externally.  This is one day.  One 24 hour period.  LIFE IS GREAT.  What a journey.  The obstacle is the way.

For the record I do NOT recommend honesty in the area of casual greetings.  It would slow us down too much and put people like me out of business.