We are in the process of revising this article.  The revised text is largely complete, although minor adjustments are still likely, links will be added, and explanatory material to go on other pages to be linked is yet to be written. The original article is available by clicking on this sentence. 

Blue font where there is no link indicates that a link to explanatory information is planned.

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. 

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. 

Next, we call attention to the fact that have generally been very disappointed in the quality of substance abuse and addiction work in programs.  In fairness to the programs, this is a very complex area and knowledge of it is changing. Our own understanding is changing, as shown by the fact that we are revising our guidelines.   We hope to provide an incentive for programs to improve. We do not assume that variance from our guidelines in this area necessarily reflects bad faith or incompetence. Some of what we advocate is quite new. Some is controversial.  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.

Central to our motivation to revise this article has been a clearer understanding of the implications of recent findings in neuroscience.  We offer a summary of thoughts on implications of neuroscience here.  For a more detailed and better documented account of the same information, please click here.  For a simpler, shorter version, continue on this page.

As addiction develops, a more primitive area of the brain (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.  The changes eventually reach a point where they are not fully reversible.  This research clarifies three points that have been long observed but not understood until this research became available:  (1) when an alcoholic in recovery takes a single drink that person may be immediately back in full blown alcoholism);  (2) that an alcoholic genuinely wants to stop drinking doesn't mean that the drinking will actually stop, and (3) why some addicts in recovery strongly identify with twelve-step principles and others cannot connect them with their own experience.

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 them and in many cases to guide the application of external resources to address them.   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.  In addressing the second task, it is important to realize that even when interrupting the addictive behavior is seriously challenging, it does not follow from that fact alone that a recidivistic pattern of addiction has already been established. It might never happen. The potential permanent changes in the brain mentioned in the previous paragraph might not have occurred at that point, although the person must be understood to be at high risk for that in the future.  The most important change in this update of these guidelines is our recognition that these are two separate tasks.

Most treatment programs either ignore the second task or else approach the second task by giving the message that the clients/patients/students are already established as addicts for life whether or not there is evidence to support that.  Programs that do not follow twelve-step principles tend to make the former mistake; those that do follow twelve step principles tend to make the second although strict application of the formal and informal traditions of most twelve-step groups would prevent that mistake. 

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, treatment centers 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.   There are others who are subject to a lifelong pattern of recidivism if they do not maintain a lifestyle built around the concept of maintaining remission or recovery.  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 established.  We refer to the former situation as "addiction-1" and the latter as "addiction-2." 

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 and 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.  We object to schools, programs, and other treatment resources imposing the "addict"  label and allowing peer pressure to impose the addict label, where the evidence supports only addiction-1 and the label imposed is meant to imply addiction-2.  Naysayers to twelve-step work rightly join us in objecting  to this but in too many cases also (wrongly) reject even the possibility of addiction-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  . . .   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, 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.

Therefore our guidelines call for all people in treatment 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.  It is never appropriate to dismiss addictive behaviors as simply "a symptom of an underlying problem." 

When addictive behaviors are an issue in treatment, 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.  In this case we are talking about both addiction and a propensity toward recidivism.  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. 

The practical result of this is to realize that people who have reached the stage of irreversible brain alteration (and therefore are addicted-2) are likely to need ongoing attention to the situation – and within a population of young people in treatment for addictive behaviors, the treatment providers rarely have the ability to know which ones they are.  For this reason relapse prevention methods and use of support systems for continued remission must be taught for compliance with our guidelines. But once again, this does not warrant imposing the concept of addiction-2 on the person if we do not know that is the case.  

The kind of support that is found in twelve-step groups is highly relevant to this situation for those addictive behaviors that are associated with the more common twelve-step groups.  When the behavior at issue is drug or alcohol use, then relevant  twelve step groups are everywhere.  When the behavior is cutting or other forms of self-mutilation, they are not. When there are ubiquitous resources to address an addiction-2 situation, then it is simple common sense that the people at risk for addiction-2 should be taught how to use them.  For emphasis: the indictor is "at risk for" as is true of people who are addicted in the sense of addiction-1 without trying to convince them that they already are addicts in the sense of addiction-2, except possibly in the very rare situations where there really is evidence for addiction-2.

This is not to imply that exposure to twelve step methods is an absolute requirement of our guidelines even in the case of substance abuse .  The requirement of our guidelines is that the program include realistic preparation for a viable support system and relapse prevention.  The problem in not supporting twelve-step work is finding another support system that is just as accessible.  This is possible at least in theory.  For certain populations there are reasonable alternatives.  FamilyLight ^sm  is not currently aware of alternatives for substance related addictions that are as broadly accessible as twelve-step groups. We do know of them for certain stationary populations in certain locations.  We are open to learning about others. 

On the other hand, if twelve-step exposure  is to be used so that people will be prepared to use the resources of twelve-step work at least if they find themselves trapped in an addiction-2 situation, perhaps some will want to use the twelve-step resources to establish initial remission even when they might only be dealing with addiction-1.  Some participants may choose choose twelve-step in response to addiction-1. If presented accurately, twelve-step can be a very useful tool in that situation, as well.

Some of the "packaged" approaches (Smart Recovery, Rational Recovery, Seven Challenges, for example)  directly focused on conscious choice and lack any obvious content impacting stress.    They appear to have significant value for addressing addiction-1.  We do not see how they impact addiction-2, based upon what we understand of the neuroscience.  Specifically, we do not see how they would help with the limbic/midbrain imbalance between pleasure, stress, and motivation for survival. We only see them as helpful in reinforcing conscious decision making, which has little influence over addction-2.   We could reconsider this observation if the proponents of those methods would offer an explanation.   We do see why twelve-step work and a number of faith-based approaches would have impact on addiction-2.

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. 

Actually, most 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.  Schools and programs that claim to be doing twelve step and are not are of great concern to us.  For detail, see our twelve-step guidelines. 

Lu Vaughn of Second Nature Blue Ridge is a therapist we greatly admire.  Lu is fond of saying, "What is the difference between treating an addicted kid compared to a substance abusing kid?"  Then giving the answer, "None."  With rare exceptions that answer is right on target.  Almost all the time, when teenagers or young adults enter a therapeutic school or treatment center with a substance abuse history or history of other potentially addictive behaviors, no one knows for sure where they are on the addictive spectrum.  Involving the residents in healthy activities that guide away from addictive behaviors and teaching about addiction are constructive at any point. 

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 potentially addictive behaviors.  Neither of these resources appear to stand alone.  Motivational Interviewing can enhance the effectiveness of any other resource for addressing addictive behavior.   Stages of Change (also known at the Transtheoretical Model) both offers support for other approaches to substance abuse intervention, and, more importantly, offers a framework for measuring progress, regardless of the primary approach in use. 

As schools and programs address initial remission, there are many approaches that can be helpful.  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 consistent 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. 

We also object to programs taking the position that addiction or substance abuse is always just a symptom of "underlying causes."  Recent findings in neuroscience have discredited that. Although it is true that some substance abuse is self medication, and other addictive behaviors have been 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) regardless of these factors. 

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 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 we accept that schools and programs will often appropriately differ from our point of view in matters that research has not settled).

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.. 

Please note that we do not require use of twelve-step programming or any twelve-step rivals as a condition of meeting out guidelines. We do require use of Motivational Interviewing and Stages of Change in order to meet our guidelines.  We see those as universal resources in combination with other resources.  

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.  

We have little confidence in standard credentialing for substance abuse workers and clinicians. (Exception regarding psychiatrists and other physicians 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 wonder why they can't tell us something more relevant about why we should suspect that they are competent in this area. We don't object to people having such credentials; we object to anyone thinking usual credentials are sufficient to prove competence.  We want to know more than that about them.

We want to know that they 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 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 do expect that they have experienced participation or observation of various self-help groups addressing addiction. We want to know they have basic counseling skills. We 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 not, 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. 

We expect schools and programs schools and programs to choose their methodology informed by competent substance abuse clinicians. Since we are most familiar with truly bad decisions about this being made on the question of whether or not to use twelve-step methods, and if using twelve step, what form it will take we will address some basics. This topic will be addressed in more detail in our guidelines on twelve-step recovery. 

The worst example of ignorance on not considering non twelve-step resources, is simply the attitude from some twelve-step people that says that nothing other than twelve-step people have anything useful to say about addiction. Even well managed, effective twelve-step programs will find that the wisdom of Smart Recovery and Seven  Challenges have  something to add.  Of those that claim to do twelve-step, there are those that teach the steps but never expose their enrollees to genuine meetings of established twelve-step fellowships. That is rarely effective and contributes to people getting a sense that twelve-step work is not effective.

The worst example we see of ignorance in not using twelve-step recovery involves people who say you simply cannot get teenagers to buy into the twelve steps. They may go on to cite the spiritual component and/or the language about powerlessness. People who make that claim simply are revealing their own lack of competence in the addictions and nothing more. 

Point by point summary

1. Our guidelines call for all schools and treatment centers which accept enrollees with  a history of some addictive behaviors, are guided in their approach to working by people who have genuine expertise in addiction therapy as described above.  We do not perceive that standard credentialing for addiction and/or substance abuse clinicians is adequate to assure competence in this area, except for ASAM certification for physicians.  This applies to all facilities accepting such enrollees regardless of what other behavioral or clinical issues may present themselves. 

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, the eliminating addictive behaviors must be a focus of treatment and all of the following 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 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.

6. Our guidelines call for integration of Motivational Interviewing and Stages of Change into all programs serving populations with a history of addictive behaviors.

This list to be expanded.

We are in the process of revising this article.  The  revised text is largely complete, although minor adjustments are still likely, links will be added, and explanatory material to go on other pages to be linked is yet to be written. The original article is available by clicking on this sentence. 

Feedback is invited. We will  publish selected feedback.  Email FamilyLightResponse@yahoo.com

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 8-23-2010