It's time we confront our collective denial about addictions. It's time to stop thinking that addicts are screwed-up people and start focusing on our culture of addiction. It's time that we stop fantasizing that addicts are shooting up in dark hallways and smoking pot in high school yards and realize that our friends and families have a vast array of substances they abuse ready and available in their bathroom medicine cabinet, some of which have been prescribed by their doctors. It's time to take note of our own addictive tendencies in the way we "use" salt, sugar, coffee, wine, and other foods as well as tobacco, searching the Internet, watching television, and even exercising. It's time to stop projecting the problem on some young, dark-skinned, back alley, television hoodlum and take a good look in the mirror.
But the problem doesn't stop there. We are not only in denial about substance use and addiction, we have been fooled by television therapists, country club treatment program advertisements, and wishful but naïve thinking that people can end their addictions by going through drug treatment. Alas, the data is in and overwhelming clear. Consider the following:
Myth 1: Addicts fail to abstain from drugs because they don't work their programs.
The myth-defying truth is this: Many addicts fail because treatment programs don't work. Research suggests that the effectiveness of treatment for addictions is not only limited, with even the best treatment programs reducing people's substance use only by about 50 percent, but that motivating people to remain abstinent or in treatment has been a major hurdle. [1] According to Nora D. Volkow, M.D., director of the National Institute on Drug Abuse, about 75 to 80 percent of people who try to quit smoking relapse within six months.
In their study on relapse rates, B.T. Jones and J. McMahon found that after people had been discharged from a 10-day residential alcohol detoxification unit, 72 percent relapsed by the end of three months. [2] Further, while Alcoholics Anonymous (AA) has done much to help people get off of drugs and alcohol, its ability to motivate people to sustain their efforts is also limited, reflected by the fact that of 100 individuals referred to AA, about 50 attend initially, about 25 still attend after three months, and only about 10 are still attending by the end of the second year. [3]
A similar conclusion was reached by Jane Brody in her Feb. 4, 2013 article in the Times' science section, "Effective Addiction Treatment," which notes that treatment programs often fail, put their faith in unproven methods, and neglect to address the deeper issues that underlie addiction and relapse rates. Her message to those who have spent thousand of dollars on rehab efforts is this: "You're not alone. And chances are, it's not your fault."
Myth 2: Improving addiction treatment means waging a more effective war on drug use.
The myth-defying truth is this: The reasons people use substances are almost always more powerful than all the reasons and efforts to abstain. Simply put, if we don't figure out what's so damn good about using substances and offer people alternatives that is at least as yummy, we'll never be very successful in helping people relinquish their grip on their drug of choice.
The prevailing wisdom views addiction intervention akin to a war on drugs. Strategies and tactics include strengthening addicts' discipline, helping them resist temptation, giving them performance-enhancing drugs in the form of relapse-prevention medication, helping them redirect their thoughts away from their chosen substance, and alerting to them to the situations and triggers for their substance use.
However, this approach fails to address one central and undeniable fact: Substances are not only the enemy needing to be beaten or overcome; substances are "friends," allies, that people seek for reasons that need to be addressed. This cannot be overstated -- you can try to convince addicts that they will lose their job, their health, their relationships; you can try to convince them that their lives can be more stable, financially successful, and less dangerous; you can tell them that they will stop hating themselves, being ashamed of themselves, and having to hide themselves from people with little or no effect; and you can put them in week-long and month-long treatment centers to support their fight against drugs. And very little of this will help! What that should tell us is this: The sum total of this "war-time" spending is not as compelling as something the person is getting from using their chosen substance!
So, why then do people abuse substances? Consider the case of Emily. Emily smoked marijuana at the end of each day. She said it helped her relax after she completed the tasks of the day. Her reason was appealing -- it seemed true. Most people would never question her further. Nonetheless, I did. Here is our conversation:
Me: Tell me what it's like when you smoke marijuana in the evening.
Emily: It relaxes me.
Me: Imagine you just finished your dinner after a full day's work and you sat down and smoked some marijuana. Recall what it feels like. (I ask this question because I am not interested in her ideas or theories about why she smokes but her actual experience.)
Emily: (sits back and looks up at the ceiling looking dreamy) My mind goes kind of blank like clouds moving across the sky.
Me: Enjoy the blankness and cloud-like movement.
Emily: (a tear forms in her eye) It feels so sweet to be away from the normal world, regular life.
Me: Tell me more about life.
Emily: The things that seem important really don't matter. All day people and tasks impinge on my experience, assert themselves, dominate my life. But none of these things are real. Everything is so superficial; I am superficial. Where's the meaning, the love, the depth of life?
Emily wasn't looking to relax; she was looking for the depth of life! The reason she didn't take a bath, watch television, or go for a short walk to relax was because those activities didn't help her connect with her deeper experience. Perhaps they would for someone else, but not for Emily. Helping Emily relinquish her hold on marijuana entailed helping her live a less superficial life -- one with more meaning and depth.
My dialogue with Emily is not unusual. People don't abuse substances because they are bored, looking for stimulation, stressed, or prone to self-medicating. While these are the usual suspects promoted by psychology texts, media, even bloggers, they rarely bear fruit -- they neither render treatment programs more successful nor match people's experience upon deeper inquiry. People use substances for hundreds of different individual, almost idiosyncratic, reasons. What we need to do is caringly and carefully investigate people's actual experiences using their substance of choice in a way that assumes there are real needs and intelligence built into the person's compulsion to use the substance. Only through this approach, a labor of love really, can we can discover the deeper reasons and meaning behind people's use and abuse of substances. Further, only helping a person find alternative routes to addressing those legitimate needs will lead to sustainable treatment.
It's time to get over our addiction to denying the truth about addiction. It is not just other people who use and abuse substances, it is also us, and it is not only addicts that fail, treatment programs also fail. Further, while waging a "war on drugs" may be a good paradigm regarding criminal justice (although that too is debatable), it neglects the most glaringly obvious fact about drugs -- people want to use them for very important and powerful reasons. But there is hope -- we can learn what really turns people on about substance use and offer alternatives that will not only help people become less dependent on substances but also help them plot a course to their power, gifts, uniqueness, and aliveness.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
References:
1. R. L. Hubbard, S. G. Craddock, P. M. Flynn, J. Anderson, and R. M. Etheridge, Substance Abuse and Mental Health Services Administration (SAMHSA) and Center for Substance Abuse Treatment (CSAT), 1997, The National Treatment Improvement Evaluation Study (NTIES).
2. B.T. Jones and J. McMahon, "Negative and Positive Alcohol Expectancies as Predictors of Abstinence after Discharge from a Residential Treatment Program: A One-month and Three-month Follow-up Study of Men," Journal of Studies on Alcohol 55 (1994): 543-48.
3. N. S. Miller and N. G. Hoffman, "Addictions Treatment Outcomes," Alcohol Treatment Quarterly 12 (1995): 41-55.; J. Chappel, "Long-Term Recovery from Alcoholism," Psychiatric Clinics of North America (1993): 177-89.