If people had a place to live and other people would allow them to stay there throughout very early recovery, would they go to residential treatment for substance use disorders?
Perhaps some- but I believe that the vast majority of people who go into residential treatment are sent because no one will let them live with them (until they are done w a residential program) Or- because the legal system ordered the to either to treatment, or do time. There are numerous dilemmas and problems with this model and I believe this time has come to for a new approach.
I believe treatment can be very different than this. I saw a glimmer of this in an article in LA Time about the merger of the Betty Ford Center an Hazeldon. The new organization, under the name Betty Ford Center, will open 3 outpatient treatment centers. I am fortunate to work for a health care organization that provides the complete outpatient continuum of care for substance use disorders. It is a more expensive approach than the much more common residential treatment approach. And, the staff of professionals all possess a with minimum of graduate degrees in a behavioral health. It is a staff heavy model of care. It is more compassionate and more effective. Studies bare this out. And being more effective, it is much more cost effective. Costs are just saved down the line; something share holders and investors do not like. Of course, cost effective in health care a tricky thing, and I will leave this issue to others.
The initial foundation of one's treatment is extremely important. I break it down like this:
pre recovery; detox/initial treatment; early recovery. These three phases cover usually about the first 9- 12 months. I have found that the maintenance phase really begins closer around one year. For what its worth, most models of care would say maintenance begins after 2-3 months.
For the next few weeks or so I will be writing on the pre recovery stage. For those of you in recovery- that would be the last period before you stopped. How you were feeling, what you were thinking, and how your body was responding to the chemicals. We will pass on the drama of the BEHAVIOR before the stop.
Please share your stories.
Monday, March 24, 2014
Tuesday, March 18, 2014
Monday, March 10, 2014
BR and the pecking order
I have always found it interesting that what comes most naturally to humans is to rank themselves against/ relative to one another. Being collaborative and equal partners rarely occurs outside of basic survival. We will naturally band together if it is in our best interests, in order to survive- otherwise, well, it's a dog eat dog world. The feminist movement finally had to realize that we rarely play nice when there are outside motivators, like money.
The term pecking order comes from chickens. When you place chickens in a pen together, they will rank themselves, and it is acted out in pecking one another on the head. Then, they all settle down because they know who ranks where- worked out through pecks. We humans are not fair behind, or should I say ahead?
If you want people to work as a team, define an agreed upon, mutual enemy. Or reward, money.
People with substance use disorders do the same thing. And, for what it is worth, so do the clinicians treating them. That is to say, the clinicians rank the patients, and they also rank themselves. 28 years in mental health and substance abuse settings- this never fails to amaze and mortify me. I guess with patients it's understandable- no one wants to be the bottom of the bottom. Which is horribly wrong since substance use disorders don't discriminate... No one is on the bottom, it's a disease.
Alcohol va substances
Cannabis vs them rest
Meth vs cociane
Heroin on the bottom (junkies? a horrible term)
Needles vs smoking, snorting
mft, lcsw, psyd, phd, Md
trainee, intern, licensed
I want to say publicly that the skills I learned at Boys Republic in regards to how to un-due the vertical pecking order, and how to develop social environments that are horizontal- was the best training, the most valuable training in my career. It was a VERY difficult place to work as a person with a graduate degree working on the front lines. But, I am grateful everyday, for all that I learned. And that I left as soon as reasonable.
To Jade, Lisa, Susan, Heidi, Sterling, Diana, Bob and Yvonne: Where ever you may be, wishing you grace and serenity. My "BR" experience is on my gratitude list every day.
The term pecking order comes from chickens. When you place chickens in a pen together, they will rank themselves, and it is acted out in pecking one another on the head. Then, they all settle down because they know who ranks where- worked out through pecks. We humans are not fair behind, or should I say ahead?
If you want people to work as a team, define an agreed upon, mutual enemy. Or reward, money.
People with substance use disorders do the same thing. And, for what it is worth, so do the clinicians treating them. That is to say, the clinicians rank the patients, and they also rank themselves. 28 years in mental health and substance abuse settings- this never fails to amaze and mortify me. I guess with patients it's understandable- no one wants to be the bottom of the bottom. Which is horribly wrong since substance use disorders don't discriminate... No one is on the bottom, it's a disease.
Alcohol va substances
Cannabis vs them rest
Meth vs cociane
Heroin on the bottom (junkies? a horrible term)
Needles vs smoking, snorting
mft, lcsw, psyd, phd, Md
trainee, intern, licensed
I want to say publicly that the skills I learned at Boys Republic in regards to how to un-due the vertical pecking order, and how to develop social environments that are horizontal- was the best training, the most valuable training in my career. It was a VERY difficult place to work as a person with a graduate degree working on the front lines. But, I am grateful everyday, for all that I learned. And that I left as soon as reasonable.
To Jade, Lisa, Susan, Heidi, Sterling, Diana, Bob and Yvonne: Where ever you may be, wishing you grace and serenity. My "BR" experience is on my gratitude list every day.
Sunday, March 2, 2014
Potheads and Stoners
I found the comments made by California governor Jerry Brown on Meet The Press this morning very disappointing. He is either terribly ignorant of the potential problems that can develop from cannabis abuse or he is purposely attempting to minimize the issues so that the voters support legalization of recreational use.
I know well both sides of the arguments regarding legalization of cannabis; economic, civi liberties, 'safer than tobacco and alcohol', and so forth. I'll vote when it's on the ballot. I am most concerned about our general ignorance regarding substance use and the devastating effects this ignorance propagates. We have lost a generation of young men and women to prisons, mental illness, unemployment. These people have become marginalized and tossed aside as immoral, lazy hedonists. Potheads. Stoners.
Wrong. Harken back to the days of using leaches to treat depression and wet frozen sheets to calm those with schizophrenia.
I know well both sides of the arguments regarding legalization of cannabis; economic, civi liberties, 'safer than tobacco and alcohol', and so forth. I'll vote when it's on the ballot. I am most concerned about our general ignorance regarding substance use and the devastating effects this ignorance propagates. We have lost a generation of young men and women to prisons, mental illness, unemployment. These people have become marginalized and tossed aside as immoral, lazy hedonists. Potheads. Stoners.
Wrong. Harken back to the days of using leaches to treat depression and wet frozen sheets to calm those with schizophrenia.
Saturday, March 1, 2014
I can control it, why can't they?
Simply answered? Because people are different. People's bodies are different, people's brains are different and people's understanding and belief about the disease is different. Why do some people become diabetics and others do not? Biology and consumption.
For too many years, and still today, people treat individuals w substance use disorders as if they have a 'defect of character', are 'weak', 'lazy' or 'gluttonous please sure seekers'. This simply is not true. Often, quite the opposite is true.
One of the main factors in determining if someone has a substance use disorder is a decrease in one's ability to purposefully control that use. For example, promising oneself not to use today, only to find themselves high by the afternoon. Or, promising that they would only have one or two- and really meaning it, desiring to just have one drink- only to have blacked out after recalling having 7 drinks. The fun is gone. The intention is to control their use- just a couple, not on weekends, no hard stuff...on and on- only to find themselves in the situation they swore off.
The next significant feature of a substance use disorder is have it seep into other areas of your life, wreaking havoc, and not stopping. They use even when they strongly desires to use/drink less or not at all. Defeat. The compulsive, unwanted behavior continues- seemingly totally within their choice, in-spite of very bad things occurring in their life directly because of the substance use. Loss of relationships, financial issues, legal problems, health problems.
Why on earth would someone choose that? They don't. Choice is a very fragile human faculty. We like to think of ourselves as fully autonomous, self driven folk. Choice is a complex series of interactions within the various systems in the brain. When the cluster of 5 areas of the brain which make up the pleasure pathway is in dis-regulation- broken basically, it re-prioritizes certain chemical reactions; placing perhaps alcohol, cannabis, or opioids (heroin, Vicodin) to the top spot. Higher than food, sex, love... The experience, the manifestation of this is the obsession- the craving...the inability to make what most of us consider basic rational decisions. Like, don't shoot heroin; don't spend money on drugs when you're broke. Don't drink a case of beer, having 2 is just fine.
Why do some people appear to have 'broken' pleasure pathways, and others don't? They can have just a couple and stop; or take a few pain pills after getting their teeth pulled, and not turn into someone who rifles through your medicine cabinet looking for pills? (yes, addicted folks do that all the time when they visit there people's homes).
Well, it's a combination of factors, but mostly genetics. Some resiliency and childhood trauma factors.
Age, access and amount of consumption play a part.
The take away is- substance use disorders are biologically based brain disorders, not a character issue. Loss of control is a key indicator. We need to eliminate the stigma, encourage effective, dignified treatment.
For too many years, and still today, people treat individuals w substance use disorders as if they have a 'defect of character', are 'weak', 'lazy' or 'gluttonous please sure seekers'. This simply is not true. Often, quite the opposite is true.
One of the main factors in determining if someone has a substance use disorder is a decrease in one's ability to purposefully control that use. For example, promising oneself not to use today, only to find themselves high by the afternoon. Or, promising that they would only have one or two- and really meaning it, desiring to just have one drink- only to have blacked out after recalling having 7 drinks. The fun is gone. The intention is to control their use- just a couple, not on weekends, no hard stuff...on and on- only to find themselves in the situation they swore off.
The next significant feature of a substance use disorder is have it seep into other areas of your life, wreaking havoc, and not stopping. They use even when they strongly desires to use/drink less or not at all. Defeat. The compulsive, unwanted behavior continues- seemingly totally within their choice, in-spite of very bad things occurring in their life directly because of the substance use. Loss of relationships, financial issues, legal problems, health problems.
Why on earth would someone choose that? They don't. Choice is a very fragile human faculty. We like to think of ourselves as fully autonomous, self driven folk. Choice is a complex series of interactions within the various systems in the brain. When the cluster of 5 areas of the brain which make up the pleasure pathway is in dis-regulation- broken basically, it re-prioritizes certain chemical reactions; placing perhaps alcohol, cannabis, or opioids (heroin, Vicodin) to the top spot. Higher than food, sex, love... The experience, the manifestation of this is the obsession- the craving...the inability to make what most of us consider basic rational decisions. Like, don't shoot heroin; don't spend money on drugs when you're broke. Don't drink a case of beer, having 2 is just fine.
Why do some people appear to have 'broken' pleasure pathways, and others don't? They can have just a couple and stop; or take a few pain pills after getting their teeth pulled, and not turn into someone who rifles through your medicine cabinet looking for pills? (yes, addicted folks do that all the time when they visit there people's homes).
Well, it's a combination of factors, but mostly genetics. Some resiliency and childhood trauma factors.
Age, access and amount of consumption play a part.
The take away is- substance use disorders are biologically based brain disorders, not a character issue. Loss of control is a key indicator. We need to eliminate the stigma, encourage effective, dignified treatment.
Sunday, February 16, 2014
Why does someone choose to pick up again?
Perhaps a more illuminating question would be- why did they choose to neglect 'avoidance of' certain situations, thoughts, chemicals that will inevitably lead to picking up?
It's important to reiterate that people vary significantly in their willingness and ability to recovery. People's disease processes vary greatly. And, that people present in different stages of their disease. I speak in generalities from my personal and professional experiences. Much of what I know comes from studying the research, literature and over 25 years of work within clinical healthcare settings. and, quite literally- practicing). There are always exceptions to these generalities. I try to speak to the hump in the bell curve, as it were. There are very fascinating outliers. But the meat is in the hump.
Most relapses are days, maybe weeks in the making. That is to say, there are various changes in the brain, manifested in thoughts, feelings, moods. Small decisions. Shifts in behaviors. Conversations with oneself. These are occurring, like a volcano gurgling away, building up pressure. And then, the physical and behavioral manifestation of the disease shows itself. And then an individual ingests an intoxicant.
Addiction is a brain disease. No way to argue this point. An award winning 61 minute educational discussion film (dvd) "Pleasure Unwoven" explains this better than anything, or anyone, I have ever encountered. It's about $25.00, clips available on tube (Kevin McCauley). If behavioral health is your profession or interest, or you are in recovery- or reflecting what might be going on with your own use, I encourage you to watch this dvd. And, lest I forget, if you are wondering about the substance use of someone you love, I'd encourage you to watch the video.
Most of us are oblivious to all the chatter in our head. We are commenting and making meaning, interpreting, categorizing information faster than my little macbook pro. Some of us are more aware of these than others. We can learn to make these mental meanderings more conscious- bringing them more into our awareness. Mindfulness and meditation are just two of the better known practices.
Anger is a common trigger emotion. Anger unresolved, and instead cultivated, kneaded and regurgitated turns into a favorite resentment. One withdraws, broods, replays the insult/assault. Cherishes it. All sorts of interesting thoughts go through one's mind. Two weeks later they relapse. Upsetting emotions happens to be the most common trigger for folks w alcohol use disorder. 'Anger is the privilege of the common man'. No the folks w a substance use disorder. Ask a self identified alcoholic- they'll tell you that nothing leads to the drink faster than a resentment.
There is no way to avoid upsetting emotion. But there are MANY ways to manage them that will avoid the process and path to relapses. And yes, upsetting emotions trigger a cascade of chemicals, hence feelings, thoughts, moods. Thoughts of alcohol, cravings (which often manifest as thoughts, i.e.- the obsession); Leading to decisions and eventually picking up. In "normies", people without an alcohol use disorder, this process does not occur.
AA and the twelve steps can teach people the solutions to this process.
Different intoxicants have different triggers. That is, people dependent on heroin have different triggers than folks dependent on alcohol. More on that another day.
So, do people choose to relapse? Sure, sometimes, but the process is generally more complex than that, hence the solution is very different than 'Just Say No'.
To avoid a relapse, or slip- one must be armed with important information about themselves, and a PLAN.
How did you make a relapse avoidance plan, and what have you found to be the most important aspects and actions from it?
Most of us are oblivious to all the chatter in our head. We are commenting and making meaning, interpreting, categorizing information faster than my little macbook pro. Some of us are more aware of these than others. We can learn to make these mental meanderings more conscious- bringing them more into our awareness. Mindfulness and meditation are just two of the better known practices.
Anger is a common trigger emotion. Anger unresolved, and instead cultivated, kneaded and regurgitated turns into a favorite resentment. One withdraws, broods, replays the insult/assault. Cherishes it. All sorts of interesting thoughts go through one's mind. Two weeks later they relapse. Upsetting emotions happens to be the most common trigger for folks w alcohol use disorder. 'Anger is the privilege of the common man'. No the folks w a substance use disorder. Ask a self identified alcoholic- they'll tell you that nothing leads to the drink faster than a resentment.
There is no way to avoid upsetting emotion. But there are MANY ways to manage them that will avoid the process and path to relapses. And yes, upsetting emotions trigger a cascade of chemicals, hence feelings, thoughts, moods. Thoughts of alcohol, cravings (which often manifest as thoughts, i.e.- the obsession); Leading to decisions and eventually picking up. In "normies", people without an alcohol use disorder, this process does not occur.
AA and the twelve steps can teach people the solutions to this process.
Different intoxicants have different triggers. That is, people dependent on heroin have different triggers than folks dependent on alcohol. More on that another day.
So, do people choose to relapse? Sure, sometimes, but the process is generally more complex than that, hence the solution is very different than 'Just Say No'.
To avoid a relapse, or slip- one must be armed with important information about themselves, and a PLAN.
How did you make a relapse avoidance plan, and what have you found to be the most important aspects and actions from it?
Thursday, January 23, 2014
catching up to the evidence
most people who have a substance use disorder, (even severe), do not need to be sent off to some far off place to live for 6 months in order to gain and learn to maintain a healthy, abstinent lifestyle.
sending someone away- or choosing to go away to live for a while, is one choice, as is a hammer for a thumb tack.
i recall in the 1990's, when I worked at an acute inpatient psychiatric hospital, people staying 3-6 months. did it 'work'? now we have medicaments and other non pharmacological treatments for people, and few people ever stay that long, 3-8 days. the knowledge base (evidenced based practices) and treatments have made substantial gains in the last 20 years of the twentieth century.
the same is true for addiction medicine. the field has made tremendous gains and it is time to re- think the main thrust of treatment. Most people with insurance coverage are offered residential treatment, with few other choices. maybe a half day intensive outpatient treatment program (IOP), and little alternatives for families who teens and young adults have a substance use issue.
for most people, the choices are a short term (5-7 day) inpatient detox stay, individual psychotherapy, 12 step; with residential being an option if the criteria is met. far too few health care providers offer the assistance patients the knowledge and sustained support needed in early recovery needed to lay the foundation of recovery.
100% abstinence for the rest of one's life is not the measure of success.
sending someone away- or choosing to go away to live for a while, is one choice, as is a hammer for a thumb tack.
i recall in the 1990's, when I worked at an acute inpatient psychiatric hospital, people staying 3-6 months. did it 'work'? now we have medicaments and other non pharmacological treatments for people, and few people ever stay that long, 3-8 days. the knowledge base (evidenced based practices) and treatments have made substantial gains in the last 20 years of the twentieth century.
the same is true for addiction medicine. the field has made tremendous gains and it is time to re- think the main thrust of treatment. Most people with insurance coverage are offered residential treatment, with few other choices. maybe a half day intensive outpatient treatment program (IOP), and little alternatives for families who teens and young adults have a substance use issue.
for most people, the choices are a short term (5-7 day) inpatient detox stay, individual psychotherapy, 12 step; with residential being an option if the criteria is met. far too few health care providers offer the assistance patients the knowledge and sustained support needed in early recovery needed to lay the foundation of recovery.
100% abstinence for the rest of one's life is not the measure of success.
Friday, January 17, 2014
it's like baking...
i can cook. that is, i can put heat to meat. bbq? it just takes patience and attending. i can watch my st lii pork ribs slowly milt on my charcol q. i am not a baker. i cannot bake. but, i do understand some basic principles and facts. a baseline of excellent ingredients don't make a great cake. but, a true baker with a keen sense of taste, a soft touch, attention to every detail, an expertise in the effects of each ingredient and the discipline to see it all through...
we have the ingredients. do we have the ethical fortitude and willingness?
we have the ingredients. do we have the ethical fortitude and willingness?
Tuesday, January 14, 2014
community (non residential) based treatment
this begs the question- 'and what exactly does that look like?'
well, simply stated- it looks much like any other medical clinic, along with recovery based services.
more than a bunch of 12 step meetings all day long
more than 'one alcoholic talking with another'
more than a medication dispensary
and it need not cost 10k a month
and it will serve the needs of the average(and two standard deviations) patient
well, simply stated- it looks much like any other medical clinic, along with recovery based services.
more than a bunch of 12 step meetings all day long
more than 'one alcoholic talking with another'
more than a medication dispensary
and it need not cost 10k a month
and it will serve the needs of the average(and two standard deviations) patient
Monday, January 13, 2014
got a better idea?
i recall when it was acceptable to place anyone w a bit other than normal behavior in a psych hospital- or jail, of course. i know throughout history it was much worse, and is currently much worse on other parts of the world- see saudi arabia.
i am just tinning about people who have a substance use disorder. lets just say it, we criminal those with the disease of drug dependence. no i am not talking about when we lock up people who harm other people places or things.
but, i am not thinking about that so much today.
i am thinking about- why isn't that we send folks w significant dependence away for 3-6 months, and or more? and, we call it treatment?
the more i see, read about, learn and watch folks w substance use disorders, the more i think residential is the best answer. for most, beyond a couple of weeks, its not a good approach... or maybe not a needed approach. that is assuming parsimony in treatment.
i am just tinning about people who have a substance use disorder. lets just say it, we criminal those with the disease of drug dependence. no i am not talking about when we lock up people who harm other people places or things.
but, i am not thinking about that so much today.
i am thinking about- why isn't that we send folks w significant dependence away for 3-6 months, and or more? and, we call it treatment?
the more i see, read about, learn and watch folks w substance use disorders, the more i think residential is the best answer. for most, beyond a couple of weeks, its not a good approach... or maybe not a needed approach. that is assuming parsimony in treatment.
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