Notes on Addiction and Substance Abuse Guidelines
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This is a page of notes and clarifications on our Addiction and Substance Abuse Guidelines
Our disappointment in quality of addiction and substance abuse and treatment generally:
(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. ) . . .
Too often we see schools, programs and transition services that (regarding substance abuse and addiction) do what plays well in marketing or is politically popular or fits the biases of an owner or founder. Too seldom do we see evidence that schools and treatment programs have actually considered carefully what actually is effective and what is not, or has avoided being unduly prejudiced by popular misconceptions. In our experience, the majority of special needs schools and programs include large numbers of clients who have significant substance abuse history, but have at best a superficial understanding of the cultures of alcoholism, drug abuse, and the treatment approaches that do or do not work. This is without considering addictive behavior patterns that are not substance related, such as sexual addiction, gambling addiction, compulsive eating, etc. To far too great an extent, the same criticism applies to public and private schools with general populations.
We fully respect that many high quality schools and programs that have not adjusted to the challenges associated with the distinction between addiction-1 and addiction-2 that we address on our main page of Addiction and Substance Abuse Guidelines. We hope they will do so in the near future, but we respect that adoption of this thinking may take a while for those not previously exposed to it. We are less appreciative about schools and programs that speak of offering twelve-step recovery when they do not really do that. We are equally annoyed by schools and programs that do not support it based upon misstatements of what exactly twelve-work is and what it entails. We deplore programs like Passages Malibu that market themselves by carpet bombing the country with advertising that proposing to offer shortcuts to remission or recovery that simply appear not to square with what is known about addiction. This appears to us to be a facility based upon a most crass form of exploiting people's misery, telling people what they want to hear, with little basis in historic awareness of what has been learned over the years working with substance abuse and addiction.
More detailed information on significance of Neuroscience in addiction work:
Central to our motivation to revise this article has been a clearer understanding of the implications of recent findings in neuroscience. It is now clear that as addiction develops, the addictive behavior influences the "midbrain" or "limbic system" in a manner that distorts the usual balance between pleasure sensations, anxiety, flght- flight reactions and emergency response. At some point, as this distortion progresses, it causes the person to seek a repeat of the addictive behavior (which behavior might be use of a drug) in the same manner as the human organism seeks air, food, sexual gratification, and avoidance of threats of immediate injury or death.
In addition to that, the changes eventually reach a point where they are not fully reversible. If the addictive behavior that seems to trigger these changes stops, the progression of brain changes also stops. If the addictive behavior does not start up again, the changes may go back somewhat in the direction of where they began before the addictive behavior initially triggered change but perhaps not totally. They are more likely to, move to an entirely different status where they are less likely to immediately confuse the addictive behavior with something essential to survival, but where a repeat of the original addictive behavior would re-start that process at full intensity in an instant. However this process differs greatly from one person to another. Some can engage in extensive addictive behavior without this process starting; for others it moves slowly; for still others it moves rapidly. All of this is complicated by the fact that the brain does not fully mature until about age 25, so the jury is still out on the permanency of brain changes as they might apply to younger people.
This contrasts with rational, conscious decisions based upon sound moral reasoning, which are based in the frontal cortex of the brain. This research clarifies four points 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) that when a person with a severe addiction is in remission for a long period of time, a single repeat of the original addictive behavior puts the person back where they were behaviorally at the height of the addiction (or more concretely, when an alcoholic in recovery takes a single drink that person may be immediately back in full blown alcoholism); (3) that conscious decision-making to stop addictive behavior does not reliably lead to a the behavior stopping (or that an alcoholic genuinely wants to stop drinking doesn't mean that the drinking will actually stop), and (4) why some people who have been into addictive behaviors experience addiction and remission exactly as the twelve-step literature has long claimed and others who have gone into remission successfully cannot relate to twelve-step groups and literature at all.
As we revise these guidelines the most important change is that we are distinguishing between tools and methods that apply to establishing initial remission from the addictive behavior (which might not have reached a stage that is correctly described as an addiction) and the tools and methods that might be necessary to sustain remission over a long period of time (especially if an addiction has developed). By "initial remission," we mean the point at which the possibly addicted person stops the addictive behavior (remember, this includes use of an addictive substance) and continues to avoid the behavior and/or use of the substance at issue for an initial period of time away from very close supervision, support, and/or structured residential treatment. For a person in a residential therapeutic school or treatment center, this would mean remission for the time the person is in treatment and for the initial weeks and months following discharge or transition to a less structured setting.
Sustaining long term remission is what we hope happens for the long haul, after life has returned to a routine and "getting sober" might no longer the primary focal point of ones life. We do not believe that, except in very special circumstances that are the kinds of exceptions that prove the rule, a treatment program whose appropriate role is to help establish initial remission is in a position to know what kinds of support will be appropriate when the task turns to sustaining long term remission. If a person is back in treatment for a sixth time after five relapses in a short period of time, that is a good indicator. Our experience is that most schools and programs dealing with initial remission correctly, err by assuming one approach is applicable to all when looking at long term remission.
For those whose brains have progressed to the point where the midbrain/limbic system is over-ruling rational decision making and is not likely to return to its initial state (or whose brains will progress to that point in the future) they need to be shown the tools to deal with that situation and be prepared to use those tools. For those whose brains have not progressed to that point and will not, imposing the disciplines of long term recovery at this stage can damage credibility of the treatment process and therefore be counter-productive. But most programs we have observed that address addictive behaviors do one thing or the other with everyone. Our guidelines call for breaking out of that pattern,, as people in both of the aforementioned situations are likely to arise in most schools and treatment centers serving young people dealing with addictive behaviors.
Contemporary neuroscience has not yet told us a number of things we need to know in order to make treatment of adolescents and young adults neat and precise. We lack an effective diagnostic tool to let us know when the aforementioned changes in the brain have occurred. In addition, much discussion of addiction, including discussion that is informed by contemporary neuroscience, includes either an explicit statement or appears to be based upon an assumption that the change from not addicted to addicted involves flipping a metaphorical switch which cannot be flipped back once it is flipped. Those who state or imply this view seem to believe that at one moment the brain has no attributes of the brain after the switch is flipped and the next minute the brain has all the attributes of an addicted person.
We very strongly doubt that this viewpoint -- that an addicted person goes from having a brain that has no attributes of addiction to having a brain with all the attributes of addiction like the flipping of a switch -- will be sustained as the relevant neuroscience matures. Based upon our experience with real people and finding no contradiction in research studies, we think the process is actually a gradual one. In early stages of that gradual process, we think people reach a point where the midbrain has altered sufficiently to overpower a person's best judgment some of the time but not all the time. We also believe that particularly with adolescents whose brains have not fully matured, that the process may remain fully reversible until it has progressed quite far.
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. We believe at the higher levels of severity, addiction reaches a point where the conscious decision making process of the brain (frontal cortex, executive function) will not overcome the demand of the midbrain (limbic system) to repeat the addictive behavior. We believe that many adolescents in particular have reached a point where our original definition of "addicted" would apply to them, but where there is some room for the conscious brain to keep the addiction in check, given sufficient determination, and/or the process may yet be fully reversible. We know of no hard research that confirms or disconfirms this stated belief. However we think it is important to define addiction in a way that allows for at least the possibility that progression to addiction involves a continuum rather than a switch. We refer to the latter situation as "addiction-1" and the former as "addiction-2."
We credit Patrick Barasso, founder of In-Balance Ranch Academy in Arizona with our attention to this issue. The reader should not blame Patrick for all that we say here and we do not speak for him. But in explaining his choice to make In Balance Ranch Academy a twelve-step program, he called to our attention the inadequacy of our own prior approach.
We are concerned about the approach that the Alcoholics Anonymous World Service, Inc. and Grapevine, Inc. are taking on this issue. First let's explain who they are. Alcoholics Anonymous World Service, Inc. is a legally incorporated service organization that takes on tasks on behalf of Alcoholics Anonymous that Alcoholics Anonymous cannot do for itself. Alcoholics Anonymous itself must maintain its complete adherence to the twelve traditions and insulate individual Alcoholics Anonymous members from business matters when they need to be about their own sobriety and reaching out to others. Grapevine, Inc., is the publishing arm of Alcoholics Anonymous and Alcoholics Anonymous World Service.
If you go on the website for Alcoholics Anonymous, www.aa.org, a website actually operated by Alcoholics Anonymous World Service, Inc., you will find a link labeled, "Is AA for you?" If you follow that link, you go to two paragraphs that we believe are a very constructive guide except for a further link. That link is a twelve point questionnaire, with the suggestion that people with four "yes" answers are in "deep trouble" where the context implies that these people need Alcoholics Anonymous. The page where that questionnaire and interpretation of results appears is on the website of Grapevine, Inc.
We believe that four positive answers leads to indications that the person is almost certainly an alcoholic as E. M. Jellinek described but might be an "alpha alcoholic," a person E. M. Jellinek described as not necessarily benefitting from Alcoholics Anonymous. We don't think that everyone who gives four "yes" answers is necessarily a person who would benefit from Alcoholics Anonymous and we think E. M. Jellinek, so often cited as an authority by twelve-step people, would agree. Some might disagree and some might not be concerned about any apparent connection between E. M. Jellinek and Alcoholics Anonymous. But we still think Grapevine, Inc. is on thin ice by Alcoholics Anonymous's own standards.
The eleventh tradition of the Twelve Traditions says in part,"Our public relations policy is based on attraction rather than promotion." What Grapevine is doing is taking a page out of the book of the commercial treatment centers. Those centers promoted themselves by attempting to frighten alpha alcoholics and "addicts-1" into accepting -- and paying large sums of money for -- treatment for more advanced forms of alcoholism and addiction that were not appropriate. Now, in striking repudiation of the eleventh tradition, Grapevine, Inc. is doing exactly the same thing, with the support of Alcoholics Anonymous World Service. We think it is time for members of Alcoholics Anonymous who see the wisdom of the Twelve Traditions to assert themselves.
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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 9-28-2010
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