Addiction and Substance Abuse Guidelines
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This is our 2010 revision of our Guidelines for Addiction and Substance Abuse. The previous Substance Abuse Guidelines article is available by clicking on this sentence. This differs from other guidelines pages in several respects. It is the first of our our guidelines pages that we have revised so thoroughly since initially posting guidelines. It is the first time we have set guidelines where we believe we are proposing standards that are very rarely met by any existing school or program. It is the first to have been created specifically in response to feedback from a former client. It is the first time we have perceived the need to include a series of subtopics and a table of contents to assist on locating the information within it. As is always true of our pages, minor changes will continue to be possible.
This is also unusual in the sense that we are seriously informed both by proponents and opponents of twelve-step work. Perhaps that just means that our guidelines will be equally offensive to both proponents and opponents of twelve-step work. The two sides of that argument rarely agree on anything. We have attempted to take very seriously and address each group's criticism of the other's primary weakness to come up with a stronger approach than either.
(Blue font where there is no link indicates that a link to explanatory information is planned.)
Definitions Two Tasks in Treating
Preparing for Addiction-2
Systems and Twelve-Step Programming
for all Schools and Programs
Two Tasks in Treating
Preparing for Addiction-2
Systems and Twelve-Step Programming
for all Schools and Programs
First we point out that addiction and substance abuse are not necessarily the same thing. Substance abuse occurs without addiction and addiction occurs without substance abuse. But the concept of addiction has emerged through experience with substance abuse. The concepts are closely linked. Our concept of addiction first emerged with drug addiction. Later treatment professionals learned that alcoholism is a special case of addiction. While it remains somewhat controversial, support from research is growing for understanding many behavioral problems, especially those involving repetitive or compulsive behavior but not substance abuse, as addictions that involve essentially the same psychological and neurological processes as drug addictions.
This page began as guidelines only on substance abuse. In our first major revision, we converted it to Guidelines on Addiction and Substance Abuse. We are also introducing principles that in some cases are firmly backed by research, but some that is not. What is not firmly backed by research is also not in conflict with any credible research we are aware of and is supported by our observations, reports of others, and in some cases suggested by research even if the research is not conclusive on the point at issue. But in no case is our input contrary with credible research with which we are familiar. Readers are encouraged to point out anything written here that is contrary to credible research.
To keep our wording as simple as possible, we will refer to "addictive behavior" as any behavior that can lead to an addiction including but not limited to use of an addictive substance. We refer to "substance abuse" as use of any substance (usually alcohol or another drug) in a manner that is harmful to self. We initially refer to "addiction" as the condition of a person when that person experiences a compulsion to engage in a potentially harmful behavior repeatedly and experiences a loss of ability to exercise judgment to avoid the behavior at issue. (This differs only slightly from a dictionary definition) We say "initially" because later on this page we show the inadequacy of that definition. Operationally, it is common for substance abuse treatment programs to think of a person as addicted if he or she continues the addictive behavior after realizing it involves self harm. We will use that operational criterion as a key indicator of who is an addict.
Shortcomings in Existing Programs
Next, we call attention to the fact that have generally been very disappointed in the quality of substance abuse and addiction work in schools and programs. We acknowledge that what we call for in these revised guidelines is more exacting than what is common in the field of addiction and substance abuse. However far too many schools and programs simply are not being careful about the basics. For more detail on why we have been disappointed, click here.
If a school or program admits and retains clients with a substance abuse and/or addiction history, we expect its staff to have an understanding of substance abuse and addiction commensurate with the needs of the people enrolled. Notice that we are saying all schools and programs that admit such clients – not just those that claim to specialize in substance abuse and addiction. To do that requires relevant staff people to stay up to date in a rapidly changing field.
Neuroscience and Addiction
to our motivation to revise this article has been a recognition that our
previous version of these guidelines gave inadequate attention to recent findings in neuroscience.
We offer some of our thoughts on implications of neuroscience in
For a more simple, somewhat abbreviated
version, stay on this page. For a more detailed and better
documented account of the same information, please
click here. If you do so, you
will be guided to re-join this page at the appropriate place.
Two areas of the brain are relevant to the processes of developing and overcoming addiction. The first area is the frontal or pre-frontal cortex which houses "executive function" -- where conscious, fully voluntary moral decision making takes place. The second area is the midbrain which houses the "limbic system" where impulses toward survival and human reproduction are based along with centers that record pleasure, pain, and anxiety. Our more animalistic sexual urges are based there as are impulses to get away from a high speed truck coming straight toward us, any irrational fears, and in general things we do by habit without requiring much thought.
As addiction develops, the midbrain/limbic system progressively increases its influence over the addictive behavior, eclipsing the higher level frontal lobe or executive function, which normally controls decision making. This involves actual physical neurochemical changes. The changes may eventually reach a point where they are not fully reversible and certainly do reach that point in some people. This is the neurochemical development that accompanies ongoing patterns of recidivism in addiction. Neuroscience has also observed that this phenomenon progresses differently in different individuals, even when the addictive behavior may be identical or almost so.
This research clarifies four points (among many others) that have been long observed but not understood until this research became available: (1) Two people with almost identical behavior patterns involving substance use or other potentially addicting behavior may have very different experiences with the process of addiction; (2) when an alcoholic in recovery takes a single drink that person may be immediately back in full blown alcoholism, although others in similar situations do not have such an abrupt experience; (3) that an alcoholic genuinely wants to stop drinking doesn't mean that the drinking will actually stop and when an alcoholic says he wants to stop and doesn't, that does not prove that the alcoholic is lying or manipulating; and (4) why some addicts in recovery strongly identify with twelve-step principles and others cannot connect them with their own experience.
Two Tasks in Treating
Two Tasks in Treating Addiction
People enrolled in therapeutic schools and treatment centers who have some history of substance abuse or other addictive behaviors, need to have those issues addressed in treatment, directed by clinical staff fully competent to address. There are two tasks. One is to interrupt the addictive behavior. The second is to recognize that these people are at risk for a lifelong recidivistic pattern of addiction. But "At risk for x" does not mean that x will certainly happen.
The previous paragraph captures where most current approaches to substance abuse and addiction get off track. Almost all schools and programs we know of addressing addiction either ignore the second task (as tends to be true of schools and programs that do not embrace twelve-step methods) or they assume that the lifelong pattern of recidivism that tends to be associated from the aforementioned permanent brain changes are necessarily in place for everyone who finds a challenge in stopping the addictive behavior (as tends to be true for twelve-step based programs). We believe both approaches need to adjust.
New Definition of Addiction
This is why our initial definition of "addiction" is inadequate. We believe any definition of "addiction" is inadequate, unless it allows for at least the possibility of a continuum of severity. In simple terms, schools and treatment programs need to accept the fact that there are people who are truly addicted in a meaningful sense, who can genuinely progress beyond that so-called addiction. That is, there are people who experience a compulsion to continue substance use and/or other addictive behavior after they fully realize that what they are doing involves self-harm, yet their brain might not have reached the point of irreversible change, and therefore a lifetime of effort into addiction recovery might not be necessary. We will refer to this as "addiction-1."
What we call Addiction-1 is approximately what E. M. Jellinek in the 1960 edition of his classic work The Disease Concept of Alcoholism called "Alpha-Alcoholism." Jellinek distinguished between Alpha-Alcoholism and the forms of alcoholism that he considered to be a disease -- which he referred to as Gamma, Delta, and Epsilon Alcoholism. Professional literature supporting twelve-step methods almost always intertwines twelve-step principles with Jellinek's work and the work of his loyal followers who updated his work. It has become common among people who speak as devotees of the disease concept of alcoholism/ addiction and of twelve step work to attribute a lifelong disease to those who meet our initial litmus test for addiction. But we point out our point of view is firmly aligned with that of the esteemed Mr. Jellinek and they may be forgetting that he introduced essentially the same concept.
Others are subject to a lifelong pattern of recidivism if they do not maintain a lifestyle built around the concept of maintaining remission or recovery. We refer this as "addiction-2." The problem is that with few exceptions, neither the addict, nor the treatment program nor anyone else knows which situation obtains at the time initial remission is initially established. Although Jellinek wrote only about alcoholism and not about other forms of addiction, addiction-2 aligns with what Jellinek actually considered to be a disease. Addiction-1 does not.
We fully expect that both those who do and those who do not agree with the disease concept and/ or twelve-step work will take issue with our approach. The advocates for twelve-step work and the disease concept probably object to our insistence that there are people who have genuine difficulty stopping an addictive behavior but do not have a lifetime disease, but the simple fact remains that the originator of the disease concept claimed exactly the same thing in his classic work in 1960 and there is nothing in official literature of the better known twelve-step fellowships that disagrees. Those who oppose the disease concept and twelve-step work will probably want to dismiss what we say about addiction-2. We leave it them to try to explain away the last decade or so of neuroscience.
We hasten to add that neither
addiction-1 nor addiction-2 is a single state of affairs where everyone
to whom that applies is at the same level of severity. The point
of separation between the two is a bit blurred. We probably should
assume addiction-2 for people who truly have "hit bottom" and truly feel
powerless over the pull of the substance or the addictive behavior.
These are probably people whose brains have reached a point where the
midbrain's limbic functions will never return to the status quo ante,
but we can't prove that.
We hasten to add that neither addiction-1 nor addiction-2 is a single state of affairs where everyone to whom that applies is at the same level of severity. The point of separation between the two is a bit blurred. We probably should assume addiction-2 for people who truly have "hit bottom" and truly feel powerless over the pull of the substance or the addictive behavior. These are probably people whose brains have reached a point where the midbrain's limbic functions will never return to the status quo ante, but we can't prove that.
Our concern is to be sure that people who have
passed the threshold of Addiction-1 -- i. e. continuing the
addictive behavior or substance use after knowing it is harmful -- get
full attention for being in a state of addiction-1, being treated as
being at risk for addiction-2 and given tools to address that
if it should happen, but not having a present addiction-2 identity
forced upon them. In other words, they need to be able to acknowledge to
themselves being addicted in the sense of addiction-1 without needing to
adopt the identity of addiction-2, but recognizing the risk that they
might face addiction-2 at some point.
Our concern is to be sure that people who have passed the threshold of Addiction-1 -- i. e. continuing the addictive behavior or substance use after knowing it is harmful -- get full attention for being in a state of addiction-1, being treated as being at risk for addiction-2 and given tools to address that if it should happen, but not having a present addiction-2 identity forced upon them. In other words, they need to be able to acknowledge to themselves being addicted in the sense of addiction-1 without needing to adopt the identity of addiction-2, but recognizing the risk that they might face addiction-2 at some point.
We strongly urge our readers
considering the distinction between addiction-1 and addiction-2 to read
created by 'disease
Guidelines on Twelve Step.
We strongly urge our readers considering the distinction between addiction-1 and addiction-2 to read our section “Confusion created by 'disease concept'” in our Guidelines on Twelve Step.
Caution in Identifying
Caution in Identifying Addicts
Schools and programs, especially twelve-step programs, frequently use the word "addict" to imply an addict-2 situation, when the presenting evidence only supports addiction-1. Those that do this take the position that when we have an addict-1, that person is necessarily an addict-2. However we know of no research evidence to support that and in our own observation of young people with addiction-type issues, it simply does not appear to be true. However an addict-1 population is at very high risk for becoming addict-2.
Our guidelines to not support schools, programs, and other treatment resources imposing the "addict" label and/or allowing peer pressure to impose the addict label, where the evidence supports only addiction-1 and where the label imposed is meant to imply addiction-2. Naysayers to twelve-step work rightly join us in objecting to this. But before those naysayers take a bow, and claim to have won the twelve-step vs. not twelve-step war, we note that they usually come up just as short. With even greater consistency, they completely fail to address the risk factor for addiction-2.
Preparing for Addiction-2
Most methods of addressing addiction that are not twelve-step based are largely cerebral, point to rational choice, and seem to presume that with the right kind of effort, executive function can be in charge of decision making consistently, and limbic impulses toward addictive behavior can be suppressed by executive function. For some people that might work for Addiction-1. We don't see how it possibly can work for addiction-2, if what current neuroscience suggests is true.
Twelve-step methods and most faith based methods, along with some relaxation and stress reduction techniques appear to address limbic issues and therefore have the potential to impact Addiction-2. The power of group support associated with twelve-step meetings and some non-twelve-step approaches also appears to have some limbic impact. One overriding advantage to twelve-step methods is that a person can gain the support of a twelve-step group almost anywhere in the world. In principle we do not want to suggest that only twelve-step methods may be considered, but when a school or program opts not to introduce effective twelve-step work to people at risk for addiction-2 they have a responsibility to provide something else, equally effective and available. For a highly mobile population, we simply do not know what that is. We do know of effective local resources, especially faith based efforts, but they are hard to duplicate as people move from place to place.
Therefore our guidelines call for all schools and programs which address addiction-1 to recognize that all people who are addicts in the sense of addiction-1 are at risk for addiction-2. We expect those schools and programs to include in their process of addressing addiction-1, preparation for addressing addiction-2 in case of need. That is, the school/program doesn't impose a belief system that on account of meeting criteria for addiction-1, the student/client has a lifetime disease as represented by addiction-2. But they do educate as to the risk and very deliberately eqiup their students/ clients with the necessary tools to deal with that effectively, should it occur.
Why not all addicts are addicts-2
Defenders of taking evidence of addiction-1 and imposing addiction-2 remedies may defend it by saying, "What's the problem? We are just trying to take the safest route. There is no downside" We disagree. One young man we referred to treatment as a sixteen year old, is now thirty, has an MSW degree, and has opened a clinical practice specializing in young adults at risk. He is also married with two children, engaging in a truly conservative lifestyle. A few years ago, his parents were considering a treatment center for a much younger brother. He and his wife intervened to prevent that, taking the brother to live with them through high school. He said in a recent email to us,
"In my experience both as a patient and as a worker in the field, this type of setting often deepens the sense of shame one has and sends them on a brutal path of a lifetime of making amends. 12 step models are often used through which kids are taught that they are addicts according to the disease model, this of course refers to a chronic disease which requires a lifetime of maintenance--for me this notion was a paralyzing one. . . .
"I . . . recall leaving . . . [treatment] feeling more frightened than ever to take on the world and become a productive member of society. I recall vividly not really having a clue how to communicate my insecurities with anyone other than a mental health professional. I firmly believed that I was a damaged person that can't live a life like anybody else because I had a disease."
We can state without fear of contradiction that this young man is not addicted to anything, although in treatment he was expected to say that he was. He probably was at that time, in the sense of addiction-1. We now know that he was not in the sense of addiction-2. But treatment then did not make the distinction. He expresses clearly the downside of this approach.
More recently, we interviewed a man in his early forties. We did not take notes but what he said went something like this:
"In my late teens I became a drug addict and an alcoholic then spent nine months in a rehab. At this point in my life, I choose not to make events of my youth part of my identity. But I don't want to hide the facts of the matter from people who have reason to know. This did happen. And I have moved on and I don't want to be defined by it.
"At the same time, I don't want anyone who needs to identify as a recovering person and to focus on recovery as in a twelve-step group to be influenced by my decision."
We don't know whether this person was an addict-1 or addict-2. We do know that he is not active in addiction now or at any other time for approximately twenty years. We do believe it is important to be clear on what we are treating when we say we are treating addiction.
Therefore our guidelines call for all people in treatment or in a wilderness program or therapeutic or emotional growth school with any history of potentially addictive behaviors to be assessed to determine whether potentially addictive behaviors need to be considered an issue in treatment. Our guidelines call for this to be answered in the affirmative any time that potentially addictive behaviors have continued despite the person's awareness that they have resulted in negative consequences.
When the above is assessed in the affirmative, our guidelines call for treatment to include preparation for maintaining or regaining remission in the event that the brain alteration of addiction-2 has occurred or might occur in the future. However our guidelines also call for the treatment not imposing the "addicted" label (if that is to imply what we are calling addiction-2) when we do not know that is the case. This is intervention or treatment with respect to addiction-1 but prevention with respect to addiction-2.
Support Systems and Twelve-Step Programming
This brings us back to the debate about using or not using twelve-step methods. Conceptually, we are open to alternatives. We do not think twelve-step approaches to substance abuse and addiction are perfect. But in practical terms we do not know where to find a similarly ubiquitous and viable support system. Therefore our guidelines call for a comparable support system to be introduced so that people with addiction-1 can be prepared to address their needs in case addiciton-2 should emerge. If a school or program chooses not to use twelve-step work in that context pertaining to potentially addictive behaviors for which their is a twelve step alternative, we leave it up to that school or program to show us by what alternative approach they intend to accomplish this.
We do not want to imply that twelve-step is only applicable to addiction-2. It can also be a viable approach to addiction-1. However there are many viable approaches to most versions of addiction-1. Many people, including many teenagers if the exposed properly to twelve-step work, will find twelve-step a useful tool in a situation where addiciton-1 is clearly present and addiction-2 is not confirmed. However it is contrary to our guidelines to pressure people to make the statement of step 1 ("I'm powerless over X") if the person does not actually believe that. In addition, the view that the person has a disease for life that can only be put into remission but never cured will not be imposed by program operating within our guidelines when there is not clear evidence of addiction-2. This creates some complications for the person who chooses to follow twelve-step that are addressed in our twelve-step guidelines.
We often hear the claim that it is impossible to use twelve-step effectively with teens. Our position on that is that people who make that claim are only speaking of their own competence or lack thereof. Schools and programs that meet our guidelines simply are not swayed by that kind of talk but rather hire clinicians who are sufficiently competent in working with teens that they do not make such claims. This does not mean that every school or program must use twelve-step work, especially not with addiction-1. We can easily accept the notion that alternative approaches are better in some situations to address addiction-1.
We are aware of flaws and misapplications in twelve step work (as well as misperceptions about twelve-step work) that have motivated some to avoid it. We discuss those in depth on our page on guidelines for twelve step programs. It is important to us that when schools and programs use twelve step work they avoid the misapplications, address the flaws and correct the misperceptions. Far too many of the schools and programs that talk about using a twelve-step approach are not really doing that; they are teaching ABOUT twelve-step but not giving their participants an opportunity to experience it. Those programs are doing harm. This approach is rarely successful. Its participants believe they have tried twelve-step work and it was not helpful, so they are unwilling to consider a REAL twelve-step approach when they may need. For detail, see our twelve-step guidelines.
Flexibility in Addressing Addiction-1
As schools and programs address initial remission, there are many approaches that can be helpful. For practical purposes, this means addressing Addiction-1. Our criteria at that stage call for "whatever works," subject to the caveat that it is schools and programs operating within our guidelines do not badmouth methods they do not use, and otherwise function consistently with our full range of guidelines. Badmouthing comes up frequently regarding twelve-step work on both sides: Advocates of methods other than twelve-step work sometimes badmouth twelve-step work; advocates of twelve-step work tend to badmouth methods that are not twelve-step. Doing this in the presence of people in treatment is irresponsible and is not compatible with our guidelines.
Tools for all Schools and Programs
At the heart of our expectations of schools and programs in tune with our guidelines is that schools and programs apply the wisdom of Stages of Change and Motivational Interviewing We believe that both are sufficiently well established that these are essential components of any appropriate intervention with potentially addictive behaviors. Neither of these resources appear to stand alone. Motivational Interviewing enhances the effectiveness of any other resource for addressing addictive behavior, as does Stages of Change (also known at the Transtheoretical Model). Neither by itself nor a combination of the two together serves as the totality of a proper therapeutic approach to substance abuse or addiction. They serve to enhance the effectiveness of other therapeutic approaches.
Some have objected to over-use of Stages of Change, pointing out that the boundaries between the defined stages might be less precise in real situations than the research implies and that movement from one stage to the next might happen more or less quickly than suggested in Stages of Change literature. We do not choose sides on those points of controversy and do not expect schools and programs to so. (We don't mean they may not choose sides on matters clearly not resolved; we simply mean that our guidelines are neutral on this controversy.)
We do expect that what is not controversial about Stages of Change will be observed: For example a person totally unmotivated to change today will not be fully committed to successful change tomorrow. Schools and programs must not attempt to push for the”dramatic conversion.” Stages of change research tells us why that is so and introduces a vocabulary that allows us to better communicate about where a person is in his/her change process. It allows us to have reasonable expectations of what is possible in personal change, helps us to avoid setting people up for failure and helps us to understand where people are in their change process.
Addiction not just Symptom of Something Else
We object to programs taking the position that addiction or substance abuse is always just a symptom of "underlying causes." Schools and programs that meet our guidelines will not do that. Recent findings in neuroscience have discredited that. Although it is true that some substance abuse is self medication, and that and other addictive behaviors might be at least partly driven by motivation for self-soothing, that kind of thing is not always a factor in motivation for addictive behaviors. Kids may smoke pot for no reason other than they experience it as fun. Or they drink to excess because their friends do it. Neuroscience demonstrates that these people may become addicted (addiction-1 or addiction-2) whether or not these factors are extant.
To get a sense of this at a practical level, if you are or were a smoker (or you know a smoker well) think about the reasons why you (or the person you know) started smoking. Then think about the reasons why they continue to do so many years later. Rarely if ever are the reasons the same. Taking away the "underlying causes" is rarely the total solution to an addiction-1 issue and never to an addiction-2 issues. In many cases it is not even relevant. The brain processes now known to be associated with addictions are clearly and indisputably independent of any so-called underlying causes.
Supporting What has been Useful
Schools and programs that meet our guidelines will permit people they enroll to continue with support of resources that have served them well previously. If a school or program cannot or will not permit the use of a particular resource that has served an admission prospect well in the past (for example Seven Challenges, twelve-step, or Smart Recovery), in order to be consistent with our guidelines it will not admit that admission prospect.
Credentialing and Competence
We have little confidence in standard credentialing for substance abuse workers and clinicians. (Exception regarding psychiatrists and other physicians [NPs and PAs, too] who are ASAM Certified). When programs promote their expertise primarily by describing the credentials as substance abuse counselors held by their staff, we conclude that they are damning themselves with faint praise, and want them to tell us something more specific about why we should suspect that they are competent in this area. In general, those credentials have been developed by people making too many compromises with special interests within the substance abuse field to be very helpful. We don't object to people having such credentials; we just do not understand them to be sufficient to prove competence. We want to know more than that about them.
In order for the program to meet our guidelines, we want to know that relevant staff members are skilled in Motivational Interviewing. We want to know that they understand change in people's lives, including hands on experience with change in their own lives and lives of others, as well as the research introduced as part of Stages of Change. (We also want them to be familiar with objections to Stages of Change and to respect its limitations. We want to know that they have in depth knowledge of various approaches to substance abuse intervention and addiction treatment, including but not limited to twelve-step groups, faith based models, Smart Recovery, Rational Recovery, Seven Challenges, attempts at treatment by teaching controlled use, etc.
While we do not insist that they be addicts in remission or recovery, we expect that they have experienced participation or observation of various self-help groups addressing addiction. in fact limiting eligibility for hiring to addicts in remission or recovery or former addicts, seems inappropriate to us. Schools and programs with that kind of restrictive policy must justify that to us in terms of effectiveness in order to meet our guidelines. Most recovery and self-help fellowships and organizations have meetings open to non-members.
Clinicians we consider to be competent have participated in such support resources and can speak from personal experience in determining their appropriateness. We want to know that clinicians have basic counseling skills. We also want to know that they have demonstrated the ability to form positive and appropriate relationships with clients.
The point is that whether people are former users or addicts or alcoholics in recovery or none of those, being effective clinicians in this field depends upon a combination of classroom skills and life experience that is rarely captured in credentialing systems for professionals in this field.
Schools and programs are too often guided by what sells well based upon misinformation rather than what is effective. We have previously pointed out our concern about this. In meeting our guidelines the schools and programs will be guided by clinicians with genuine competence acting consistently with other guidelines referenced on this page. They will choose methodologies based upon thorough understanding of them, noting that we presume a level of understanding that can only be acquired by participation, even if participation as a non-addict visitor.
We will listen to claims to the contrary from programs using such resources, but we consider cerebral approaches to addiction like Rational Recovery, Smart Recovery, Seven Challenges, etc to be credible approaches to addiction-1 but not addiction-2.
Last but absolutely not least is the need to address and correct the family systems that support addiction. We often hear the term "co-dependent" or just "co." In the twenty-first century, it is easy to forget that the concept of "co-dependent" was preceded by the term "co-alcoholic," a reference to the spouse or other person in closest association with an alcoholic. "Co-dependent" originally applied to the person in closest association with a "chemically dependent" person. Even then, professionals working with families of alcoholics and drug addicts began to see that to a large extent the recovery of the addict (alcoholic) depended upon the the co-dependent (co-alcoholic) becoming healthy. There are multiple well known theories, tools, and approaches to family issues associated with substance abuse and addiction.
Our guidelines require attention to this. Individuals with addiction history are not likely to remain in remission if they are intimately involved in family systems or other social systems that are characteristic of systems that enable addiction. In addiction-2 situations either the system must change to a system that does not enable addiction or the addict in remission must remove herself/himself from that system. In Addiction-1 situations, the same kind of change has an enormous positive impact on outcomes.
Accordingly, when schools and programs use twelve-step approaches, we expect them to insist upon parent participation in twelve-step family group such as Al-Anon, Nar-Anon, Families Anonymous, or other similar group. We expect them also to work through issues of family systems, targeting what some have called the Drama Triangle, and other family systems issues as addressed in our Guidelines on Family Participation.
A Final Word
Our approach to this set of guidelines has been bold, suggesting a standard that we thing few if any schools and programs currently meet. We believe that In Balance Ranch Academy and Catalyst come close. (In Balance Ranch Academy perhaps a bit closer than Catalyst). We believe schools and programs that find our input relevant may want to challenge our guidelines; we look forward to their input. We are hopeful that what we propose here will lead to strongly improved services for people with substance abuse and addiction issues.
Point by point summary. This is intended to be telegraphic. Explanations are in the text above.
1. Our guidelines call for all schools and treatment centers which accept enrollees with a history of some substance abuse or other addictive behaviors to provide staff with genuine expertise in substance abuse and addiction. Except for ASAM certification for physicians, specific credentials in substance abuse and/or addiction are NOT a sufficient indicator of competence.
2. Our guidelines call for all people in therapeutic schools or treatment centers, with a history of addictive behaviors, to be assessed to determine whether addictive behaviors need to be considered an issue in treatment. Our guidelines call for this to be answered in the affirmative any time that addictive behaviors have resulted in negative consequences. When it is affirmative, eliminating addictive behaviors must be a focus of treatment and all of the following guidelines apply to services for those enrollees..
3. Our guidelines leave no room for the view that addictive behaviors are simply "a symptom of an underlying problem." (Treatment programs that reject twelve-step work frequently are inconsistent with our guidelines on this point)
4. When addictive behaviors are an issue in treatment, our guidelines call for treatment to include preparation for maintaining or regaining remission in the event of a future addiction-2 situation. (Treatment programs that reject twelve-step work frequently are inconsistent with our guidelines on this point)
5. Our guidelines oppose imposing the "addicted" or "alcoholic" label -- implying addiction 2 -- when we do not know that is the case. Usually, that cannot be determined in a therapeutic school or treatment center. (Treatment programs that embrace twelve-step work and "disease concept of addiction" frequently are inconsistent with our guidelines on this point) We do not object to supporting a person in treatment in a personal choice to use that label if they have been educated as to the issues presented in these guidelines. However, we feel it is incumbent upon schools and programs to prevent both staff pressure and peer pressure on those in the program to accept that label unless those people choose to accept in on a fully informed basis. We remind readers that classic literature of the twelve-step fellowships does not disagree and classic literature of the "disease concept" is aligned with our concern even if it is common for contemporary twelve-step fellowship members and professional advocates of twelve-step methods to neglect this fact.
6. Our guidelines call for integration of Motivational Interviewing and Stages of Change into all programs serving populations with a history of addictive behaviors.
7. Our guidelines call for addressing and correcting the family systems that accompany and support addiction. Programs must strongly encourage parents to participate in twelve-step family groups (Al-Anon, Nar-Anon, Families Anonymous, etc.) if twelve-step work part of the program of their son or daughter. Guidelines for Family Participation and for Transition and Aftercare also apply.
8. Our guidelines call for choices regarding methodologies in addressing addiction and substance abuse to be based upon accurate understanding of addiction, substance abuse and associated treatment methodologies.
9. Schools and programs using twelve-step methods will be in compliance with our twelve-step guidelines.
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Disclaimer: No program review, no matter how positive, is a blanket endorsement. No criticism is a blanket condemnation. When we express our level of confidence in a school or program, that is our subjective opinion with which others might reasonably disagree. When we assert something as fact, we have done our best to be accurate, but we cannot guarantee that all of our information is accurate and up to date. When we address compliance with our guidelines, you need to remember that these are only OUR guidelines -- not guidelines from an official source. We have also set the bar very high, and do not expect any school or program to be in total compliance. It is not appropriate to draw a conclusion of impropriety (or even failure to live up to conventional wisdom) from our lack of confidence in a school or program or from less than perfect conformity to our guidelines. Some will say we expect too much. Readers are responsible for verifying accuracy of information supplied here prior to acting upon it. We are not responsible for inaccuracies.
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Last update 1-11-2011; minor edit 2-18-2011
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