Science has served as a powerful tool to elevate the quality of modern addiction treatment, and there is no name more associated with that effort than Dr. Tom McLellan. Dr. McLellan served as Professor of Psychology in Psychiatry at the University of Pennsylvania, developed the Addiction Severity Index, authored more than 400 articles and chapters on addiction treatment, founded the Treatment Research Institute (TRI), and held the position of Editor in Chief of the Journal of Substance Abuse Treatment. He currently leads demand reduction efforts at the White House Office of National Drug Control Policy (ONDCP). His persistent and eloquent voice, challenging the field to fundamentally rethink how addiction treatment is designed and evaluated, has earned him innumerable awards from professional societies in the United States and Europe.  In this wide-ranging interview, Dr. McLellan explores his career and what he has learned from his studies about addiction treatment and the role of the addiction counselor in treatment outcomes. He also shares his thoughts about the future of addiction treatment and how he has sought to influence that future through his work at ONDCP.    

Bill White: Tom, you’ve spent your career wrestling with questions of great relevance to frontline addiction professionals. What circumstances led to your pursuing research on addiction treatment?
Dr. McLellan: Well, like almost everybody I have ever met who has been a career addiction researcher, I didn’t start out with this intent. I, like most people, had a different idea in mind. I studied psychology, but not clinical psychology. I was a rat runner and an animal learning guy with a background in physiological psychology, and that’s what I intended to do. When I got out of graduate school, there weren’t any jobs, but circumstances permitted me to buy a small farm in central Pennsylvania. I looked around for a job, and the closest one was the Coatesville Veteran’s Administration Medical Center. I went down there equipped with a degree in animal learning and nothing else, and surprisingly, they had no jobs for anybody with an animal learning degree. They did have a job as a Research Technician at that time (1975) in an emerging area of interest for the Veteran’s Administration: treating addiction in returning Vietnam-era veterans. I became enamored of the whole field the first time I walked into a therapeutic community. There were guys my age. They looked like me. They had the same background I had. I knew nothing about addiction, and nothing in my academic training prepared me for anything of it, but I immediately found it really interesting.

Bill White: One of your early interests there was the relationship between patients’ drug choices and particular types of psychiatric disorders. How did that interest develop?
Dr. McLellan: Well, once again, there was no planning involved. I was a junior faculty member at the Coatesville Veteran’s Administration Medical Center. At that time, they had about 3,000 residential beds that were constantly filled with people who had psychiatric illness, really quite severe psychiatric illness. This was the era of the first patients’ rights movement, and it fell to me to evaluate a random sample of patients and ask them confidentially about their satisfaction with all manner of things, like their treatment, the food, the doctors and all of that. Well, in the course of this, I was able to insert some additional questions about whether there had been any drug use in their history. And indeed, there was. More importantly, many of them were actively involved in using alcohol and other drugs right on the campus. I was amazed by that—showing my naïveté—so that was the first report; but the second report was a little more interesting.

Because I had interviewed these individuals without any kind of background, I later went and looked up their diagnoses. It turned out that their diagnoses were quite related to the kinds of drugs that they had been using. People who were diagnosed as depressed were often using a variety of depressant or tranquilizing drugs. People who were diagnosed with schizophrenia had histories of using amphetamine—there was very little cocaine use at that time. The people with alcohol and opiate use backgrounds had a variety of diagnoses. I wrote an early paper on this possible relationship.

This led me to ask such questions of current patients, many of whom had been coming to the Veteran’s Administration for a number of years. By tracing back their early psychiatric test results, I found over a six year period, in a sample of people who had returned to treatment every year for six years, that there was a progressive development of psychiatric problems that mirrored the actions of the drugs they were using. Particularly interesting were the changes in psychiatric diagnoses among people who used amphetamine/methamphetamine over a six year period. They moved from being treated primarily in the drug unit, to being treated in the psychiatric unit, and finally, into locked wards. It looked as though, after some period of time, the symptoms that were purely drug-related and temporary ultimately ended up being permanent or semi-permanent. The same thing happened with people who used combinations of alcohol and depressants. Depression—significant, serious depression—was sustained. Also interesting, we saw no major changes in the psychiatric problems of people who used opiates or alcohol.

As a point of potential interest to young researchers, I wrote these findings and tried to present them to the American Psychological Association, and they turned it down flat. A friend of mine said he thought it had some medical interest, and it was later a lead article in the New England Journal of Medicine. So, for young people who are starting out, don’t get too worried if you get a rejection. The other point of interest is that much of what I’ve learned and done was not achieved through planned studies and experiments, but by being in a clinical situation and keeping my eyes open and listening to the clinicians and especially to the patients.

Bill White: That reinforces for our readers the importance of observation and reflecting on those observations.
Dr. McLellan: Yes. Today, I’m in a policy office and haven’t had patient contact for several years. I miss that very much. Very selfishly, if you don’t have direct patient contact, it’s very difficult to come up with sensible, relevant clinical ideas.

Bill White: Many of our readers at Counselor know you through your work developing the Addiction Severity Index. When you look back over the years since its original development, what are the most important things you have learned about the process of clinical assessment?
Dr. McLellan: There’s a real theme emerging here. The Addiction Severity Index was completely unplanned. It was born entirely of clinical necessity. I was working in a residential therapeutic community, and every patient who came into treatment was clinically staffed. Staffing meant that you had—boy, these are the old days—a psychiatrist, a psychologist, a nurse, a counselor, a social worker, an employment counselor and someone from administration. Every person who came in sat at the end of a table after they stabilized and were interviewed by all of these people from the various service areas. I was asked to develop something that would be easier and faster than this rather grueling 90-minute process. So, I tried to distill the questions that had been asked by those various service representatives into questions that could be asked by somebody with far less training. I had two goals in mind: 1) getting an initial assessment of the severity of the various kinds of presenting problems; and 2) developing a sort of screen through which this initial assessment might lead to more detailed professional assessment.

So being very proud of myself, I showed it to the clinical staff.  They didn’t like it one bit, primarily because it was filled with numbers, and the numbers couldn’t really translate into something that they were used to—a nicely written, professional admission note and a treatment plan. So I said, “You don’t want a researcher without a lot of clinical experience doing a treatment plan, so suppose I just summarize the information in each area into a single severity as a single number?” And that’s what I did.  I had already named it the Addiction Severity Index because I fully expected that all of the problems—the employment, the legal, the medical, psychiatric, etc.—would be the direct result of the severity of the drug use. Well, I was amazed to find that that was not the case.

People with the most severe drug problems often did not necessarily have the most severe employment or psychiatric problems. People with really severe psychiatric problems, for example, often did not have severe drug problems. I had named it an “Index” because I thought we could add up all the numbers into one single number, but that was clearly not possible given what we were finding. But more importantly, it suggested to me from the very beginning that “addiction related problems” can be related in very different ways. Some problems cause substance use; some problems result from substance use; and some simply emerge along with substance use as the result of genetic, personality or environmental conditions. This was one of the most important things I ever learned about addiction. Like many of the people I meet in my current job, I too thought that if you just reduce the drug use, all the other “drug related” problems would disappear. This was, and still is, a very naïve view. Worse, it has been a very big force in the way the original—and some of the existing—treatment programs were conceptualized, designed, funded and evaluated.  

Bill White: You have challenged the field to make addiction treatment more attractive and engaging. How might addiction professionals working in local treatment programs contribute to that goal?
Dr. McLellan: I do think treatment has to be more engaging, but I also have to first say that it’s quite easy for a guy who’s sitting at a desk here
in Washington to start making pronouncements about what clinicians working every day with very difficult patients ought to do. I do know that none of what I am about to say is easy to do.

I’ve spent my whole career looking at all of the kinds of things that have been tried—at least in this country—to reduce substance use problems, and treatment is by far the best. So, my whole goal from early on has been to find ways of getting more people into treatment and keeping people who are already in treatment, in treatment longer. With that proviso, let me begin by saying that the nature of most existing addiction treatment has not been particularly attractive to most of the individuals who could benefit most from it. That is not my opinion; that is just simple fact. We have between 23 and 25 million people with diagnosed substance use problems in the country, and on any given day, there’s maybe 2 to 2.5 million of them in treatment. So, only one-tenth of those with a diagnosed illness are receiving care. More importantly, that 10 percent is by no means representative of the rest of the 25 million people. They’re the most severe. They’re the most chronic and difficult. Most of them have been forced into treatment. Further, they’re in treatment that is typically segregated from the rest of healthcare. So I don’t see this as the best way to attract more people into treatment or to keep patients in treatment longer.  We have to find ways to make treatment more attractive and effective for this larger population.

Bill White: Tom, do you see a day when addiction counselors will be working in a wide variety of settings outside of specialized addiction treatment?
Dr. McLellan: Yes, I do. In this policy environment that I’m in now, one of the emerging themes is integrating addiction treatment into mainstream healthcare. I know a lot of readers are going to get very worried about that. They know the bad old days when addiction was treated under the mental health umbrella and was viewed as merely a symptom of an underlying depression or personality disorder and never given the emphasis it properly required. I hope that doesn’t come back, but here’s the other truth: addiction treatment as a field is currently reaching only a tiny fraction of the people it should reach.

Addiction is causing and is complicating a lot of medical disorders. Mainstream healthcare has never really paid the attention it should have to addiction related problems in the mainstream healthcare system. Meanwhile, as addiction treatment has become more segregated, budgets have been reduced virtually every year since I’ve been working in this field. I know of no kind of treatment, education or public enterprise that is best when it is segregated. So we’re trying very hard to bring addiction treatment—particularly screening and early intervention with mild to moderate substance use disorders—into lots more healthcare settings, particularly primary care and family medicine centers. Importantly, I am talking less about “addiction,” than about the less severe and less chronic forms of substance use—unhealthy use, problematic use, etc.  We’re trying to develop more and more varied kinds of treatments: treatments that will involve medications, treatments that will involve families; treatments that will involve whole communities. We are hoping that different types of treatments for mild to moderate substance use problems, delivered within the same context as the rest of medical care, are more attractive and engaging to those who will not even consider treatment now.

And if you’re wondering if I’m ever going to get around to answering your question, in every one of these environments, there is a need for workforce. Certainly physicians are not going to do this alone. Nurses, counselors, psychologists and social workers are going to be needed. Behavioral health disorders so complicate other health disorders that all of these conditions need to be treated in an integrated fashion. So, we need more counselors and other behavioral health specialists ready to rise to this challenge. Tomorrow’s counselor is going to need to know a lot more about medicine, a lot more about genetics, and a lot more about case management. It will be a quite different role in the coming years.

Bill White: One of the questions that you’ve researched that will be of great interest to the readers of Counselor is whether the counselor is an active ingredient in addiction treatment outcomes. Could you summarize what your research revealed on this question?
Dr. McLellan: The research that I did on counseling was among the more interesting chapters in my professional life. Once again, it started in an unplanned way. I was, by this time, working with George Woody and Chuck O’Brien at the Philadelphia VA Medical Center in a large methadone treatment program. Two counselors, each with a very large caseload, both quit at the same time. Their patients had to be reassigned and because time was of the essence, they were simply distributed among four other counselors. This gave us an unplanned but very real opportunity to see if the counselor made a difference in patient outcomes. Remember that all of these patients had been stabilized on methadone. All had been in treatment for at least six months. They all had had a counselor, and now, we’re going to lose their old counselor and get, through what was basically random assignment, one of four new counselors. Well, it turned out that the counselors that they got really made a significant difference. Patients did reliably worse when they got changed to one particular counselor. Others assigned to a different counselor did reliably better. Turns out—surprise, surprise—not every counselor is a good counselor; and some counselors are really extraordinary.

This early finding led to a much more systematic effort. During the rapid expansion of methadone treatment in response to the AIDS epidemic, there was a call for “minimum methadone,” basically methadone alone, without any kind of counseling. This was and remains a well-intentioned effort to get this very potent medication to people who are using street opiates. So we asked, “Is a counselor really necessary?” We did a randomized controlled trial where patients got very minimal counseling—only an admission assessment—and then were brought up to a pretty conventional dose of methadone. A second group got the same methadone at the same dose, but they got regular, standardized counseling using the kind of model that the Johns Hopkins folks have used, developed by Maxine Stitzer. The third group got the same methadone, the same counseling as the second group, but they also got access to lots of social services: employment, psychiatric, medical care. The findings on any measure that you wanted to look at were just like a dose response. Patients who got methadone alone did show improvement, but it was modest; it was minor. Many of them had to be essentially rescued and then received more counseling. The patients who got exactly the same methadone dose plus counseling did much better, and the patients who got the combination of methadone, counseling plus additional social services did the best. In terms of cost-effectiveness, it was methadone plus good solid counseling that was best.

So that affirmed for me in both clinical ways and in cost-effective ways that counseling was essential. But the other thing that’s as important to say again is not everybody can be, or ought to be, a counselor. There are protocols to do counseling that can be combined with case management and information management. I’m afraid that not enough counselors are learning counseling as a profession. They’re simply being thrown into it and asked to “do group.” That’s not counseling.

Bill White: You’ve spent much of your career assessing the relative effectiveness of addiction treatment. What major conclusions have you drawn from the treatment effectiveness research?
Dr. McLellan: My idea was to look at the relative effectiveness of addiction treatment versus some other illnesses that I thought the public and certainly, I, felt were really effectively treated. I thought about conditions like hypertension, diabetes and asthma. I picked those because they were inarguably real medical conditions, and candidly, I really expected to see excellent results. So when my colleagues and I—Herb Kleber, Chuck O’Brien, David Lewis—did a literature review and looked at articles from the prior 10 years, we were frankly all amazed by it. There were so many similarities. The twin studies showed that the genetic heritability of opiate, alcohol, cocaine, and now marijuana dependence, was very similar to the heritability seen in twin studies of hypertension, diabetes or asthma. Management problems were almost identical. The biggest ones were lack of adherence. About 50 to 70 percent of patients who are in treatment for diabetes, asthma or hypertension don’t take their medications as prescribed and don’t follow through with recommended life changes suggested by their physicians. Correspondingly, the relapse rates are about the same: roughly 50 percent per year. Even the predictors of relapse were very similar: low socioeconomic conditions (i.e., poverty; poor family
supports; genetic heritability; and psychiatric symptoms) were all major predictors of relapse, not just in addiction, but in hypertension, diabetes and asthma. Subsequently, I’ve seen studies that have shown the same thing in response to dental management.

There are two conclusions I’ve drawn from all this. One, from a clinical perspective, I think addiction has much to be proud of—but also a long way to go. With far less support, far less organization, but far more use of individuals actively managing their disease (people in recovery), we’ve managed to have roughly the same levels of success and unfortunately, failure as other major illnesses. I think the next steps for our field are to incorporate some of the lessons learned from the management of other chronic illnesses. The second conclusion is that guys like me have been evaluating addiction treatment in the wrong way for a very long time.

Because addiction has been segregated, because its origins haven’t been understood, because addiction causes so many social problems, it’s been easy to think of addiction as a moral problem or a sin, and those who are addicted as simply criminals who need to be punished, taught a lesson, all that. God forbid you would have attractive, long-term treatments for that kind of a person. No, you want acute care, short and punitive. Better if they don’t like it. Better if they learn to get discipline and take their medicine.

Well, that is not the way you treat other chronic illnesses. It’s not the way you treat illnesses that don’t have a cure, and I don’t think we have a cure for addiction. We’ve had explicitly as our therapeutic goals to get people out of addiction treatment as soon as possible—to get them graduated. The rest of medicine realizes that if you don’t have a cure, the best thing you can possibly do is keep people in treatment. I’m not talking about residential care for the rest of their lives, but keeping them engaged in outpatient treatment for at least a year, perhaps two years, where relapses are anticipated, caught early, and intervened upon directly and therapeutically. That’s one of the most important lessons I have learned.  

The third and final thing I’ve learned is not only have we been evaluating it the wrong way, the government has been purchasing it the wrong way. The government is not purchasing the kind of sustained, outpatient, continuing, multifaceted care that the evidence shows has the best results. The government spends a lot of money on short-term detoxifications not followed by any other kind of care. That is money wasted.

Bill White: You recently collaborated with Deni Carise and Herb Kleber to address the question of whether the current infrastructure of addiction treatment could support the public’s demand for quality treatment. What were your conclusions that you drew from that study?
Dr. McLellan: I’m sorry to say that I have a very negative view about the current status of the United States addiction treatment infrastructure—particularly the infrastructure in the public treatment sector. I want to hasten to say I don’t hold the treatment professionals responsible for this state. I hold the government and the public responsible for this state.

We have brief interventions to intervene early in the development of substance-related problems that are very clinically effective and cost-effective. We’ve got medications for opiate, alcohol, nicotine, some indications for cocaine, not much yet for methamphetamine treatment, but we’ve got good medications. We have many evidence-based therapies that require sophisticated therapists, but that can have enduring benefits. These are not simply my opinions but facts based on two decades of very good research.

Well, the average treatment program in this country simply cannot implement most of those treatment ingredients. Most do not have a doctor, so medications are out. Most do not have integrated information systems, and there are government regulations that prohibit exchange of information between addiction treatment and the rest of healthcare, so case management and information management is very difficult. Most treatment programs don’t have a workforce that’s been adequately trained and clinically supervised.  Worse, because of contemporary funding constraints, I’m sorry to say I don’t think significant upgrading of training or clinical services is going to happen in these programs, again, in some significant part, because addiction treatment is segregated from the rest of healthcare financially, administratively and in terms of regulations and information.  
I do think it’s going to be a difficult transition, make no mistake, but I think ultimately the future of this field is to become part of the rest of healthcare. By the way, I’m not saying we should become integrated simply because it’s time for the rest of healthcare to do the addiction field a favor or even because it’s the right thing to do—although it is the right thing. No, I think integration of mental and substance use care into the rest of healthcare is one of the biggest favors we will ever do for mainstream healthcare in this country. Truly integrated healthcare will produce far better and far cheaper healthcare generally, and particularly for the many millions of ­people who currently have a range of untreated substance use disorders.

Bill White: One of the issues that has dominated many discussions in this past decade is the whole issue of the gap between clinical research and clinical practice as one dimension of this larger quality of treatment issue. What are your current views on the issues related to that gap between research and practice?
Dr. McLellan: Well, I think there’s no doubt about it. Elizabeth McGlynn, from RAND, published a study a few years back showing that in terms of integrating evidence-based practices—that is, clinical practices that research has shown to be effective—the treatment of alcoholism ranked among the lowest of all the medical treatments studied (she was not able to study drug abuse treatment). Of course, there is a research to practice gap in every healthcare disorder, but the gap is bigger and wider in the substance use field. Once again, I have to say I think it’s partly a function of segregation.

While much of the addiction treatment system is segregated from the rest of healthcare, most addiction researchers are very integrated into mainstream academic healthcare settings. So the medications, therapies and other interventions are generally developed in more academic,
full-service environments, often with better trained staffs and research infrastructures to back them up. That kind of infrastructure just isn’t available in the mainstream field, and thus many of the treatments that are studied and shown to be effective simply won’t fit in the “real world.” So, who do we blame for this—the researchers for working under very good conditions; or perhaps we should blame community treatment providers for working in much more difficult situations? Neither of these makes sense. We need to put infrastructure dollars into the kinds of treatment interventions that have the best results. Isn’t that what they do in the treatment of other illnesses?

Bill White: I was really struck by one of your recommendations to enhance the quality of addiction treatment resources. You recommended that addiction treatment be formally declared a distressed industry to bring additional resources to support workforce development. What do you think are some of the most important next steps for workforce development in the field?
Dr. McLellan: This is not an opinion; this is a fact. We don’t have near the number of trained professional counselors, social workers and psychologists working in the addiction field that we need right now. Second, a significant proportion of those people who are working are at or near the retirement age. Third, we don’t see new people standing in line to enter this field. That’s not all; the problem is going to be even worse because, as I’ve said repeatedly throughout this interview, the future is integration into the rest of healthcare. So, not only will we need to retain the professional skills and professional knowledge about substance use disorders that we’ve acquired over the last several decades and impart that to new people, we need to also upgrade our training. Counselors need to know much more about the genetics of addiction so they can explain to the families and the patients some of the origins of these illnesses. Case management skills are going to be necessary. Fundamental knowledge about medications as well as knowledge about, and ability to describe different kinds of treatments are all going to be important skills.

The labor department, who we’re now working with, is responsible for the training and development of workforces. In the past in this country, the declaration of an area of commerce that has particular importance for our society and has suffered workforce problems (e.g. electronics, alternative energy, farming, etc.) has been associated with an infusion of new money, new training programs, new credentialing and skill development programs all from the Department of Labor. Those kinds of interventions have been responsible for some of the dramatic developments in the electronics and farming industries in this country. I think they ought to be brought to bear in the behavioral health field, particularly addictions.

Bill White: I’ve acknowledged the article that you, David Lewis, Charles O’Brien and Herb Kleber published in the Journal of the American Medical
Association in 2000, on addiction as a chronic disease as a historical milestone in modern thinking about addiction treatment. What progress have we as a country and a professional field made since 2000 on our understanding of addiction as a chronic disorder requiring sustained recovery management?
Dr. McLellan: I don’t think we’re anywhere close to where we should be in terms of accepting addiction as a chronic illness, and—more important than anything else—acting on those expectations. In my current role, I am surprised virtually every day to meet people in highest levels of government agencies that work in the drug arena that have never imagined that addiction has public health implications. They think of it entirely as a criminal justice issue.

They say, “Well, if it’s an illness, it is one brought on by the individual” or “If it is an illness, it’s not a real illness.” They don’t understand that most illnesses in this country, particularly chronic illnesses, are brought on by the behaviors of those who ultimately contract the illness. Adult-onset diabetes, hypertension, asthma, tooth decay, lots of them are brought on by behaviors combined with genetics, and they produce really significant public health conditions that are unambiguously treated in healthcare  settings.

Perhaps worse, I hear lots of people who are working in the addictions field say the words “addiction is a chronic illness,” but they keep doing the same acute care kinds of treatments and addiction researchers keep evaluating the effects of addiction treatment with 12-month post-treatment outcomes. Insurance coverage for addiction treatment has finally begun to realize—as a result of parity legislation and now through the Healthcare Reform Act—that addiction ought to be managed the same way, in the same kind of an environment, with the same kind of clinical information exchange as other chronic illnesses.

Bill White: If we really did treat addiction as a chronic disorder, how would the current role of the addiction counselor change?
Dr. McLellan: Despite all the problems we have in our field and all the things we need to develop, we have one of the best fundamental models for the treatment of a chronic illness that you’re ever going to see. The addiction field has learned to integrate criminal justice interventions, where necessary, with therapeutic interventions, and that is a very important part of maintaining public health and public safety. Second, we have some of the most cost-effective and lasting recovery-oriented interventions that I know about in medicine. We found ways to get people who are recovering from addiction to work with others who are just entering or just thinking about entering recovery. I can’t think of a more cost-effective model for maintenance of treatment effects, and we are now seeing treatments for other chronic illnesses incorporating peer-led continuing support. So, all that is something we should be rightly quite proud of.

Recovery-oriented systems of care are starting to emerge in many places as they are now in Philadelphia and the state of Connecticut. As far as I’m concerned, they offer a very nice model for how you should treat other chronic illnesses in a cost-effective manner. With that said, I think people with behavioral health experience—counselors, social workers, family counselors, psychologists—who learn about addiction and learn about the methods to manage it through combinations of medications, family involvement, peer involvement, monitoring and social supports are going to be invaluable, not just to the treatment of addiction, but to the treatment of chronic illness generally.

Bill White: It is interesting to me that at this late stage of the field’s development, we are just getting around to defining recovery. You led the effort by the Betty Ford Institute to assemble a consensus panel to create a working definition of recovery. What would you say you’ve learned from that process?
Dr. McLellan: I think one of the more satisfying things I have been part of in my career was the effort by the Betty Ford Institute with a lot of other professionals—including yourself, Bill—to take on the task of defining recovery, not for the person who is in recovery, but for the great majority of the world who don’t know anything about it and often have misgivings and misunderstandings about the concept. It was challenging to develop a succinct way of presenting what is a very complicated concept. I took three lessons from this experience.  

First, there is no single way to get into recovery. That was a lesson I learned from you, Bill. The most popular and storied way of getting into recovery is through involvement in a 12 Step program. It remains one of the staples of our field, but it’s not the only way. Second, abstinence is necessary but not sufficient. People who simply don’t drink but continue behaviors and attitudes that are associated with an addiction lifestyle are not going to be abstinent for long as far as I’m concerned. Third, probably more important than anything else, is that recovery is not only achievable, it’s downright expectable.

There are, according to the Faces and Voices of Recovery, at least 20 million people today who consider themselves to be in active, stable recovery, and the public at large has no idea about that. Too many think that addiction is a lost cause. They think that there’s no real hope, and unfortunately, it’s because they don’t know that they are quite literally surrounded by people who are in recovery but don’t talk about it every day. This is one of the things that we want to make clear to the public: that recovery is not only possible, it’s expectable, and it should be the goal of every treatment episode. Having a solid, well supported recovery community is a tremendous resource for any community and any family and any individual.

Bill White: Were you surprised at the international interest that the Betty Ford Institute recovery definition consensus generated?
Dr. McLellan: Actually, no. Once you have a definition that people can agree on and can measure in sensible terms, the hardest work is done. I was quite certain that this process of defining recovery would be well worth the effort, and it has been. Countries all over the world are interested in adopting the definition or some variation of it. More important than adopting the definition—although I think that was the necessary first step—they’re developing strategies to bring recovery into much broader reality. That’s what’s been really gratifying about this work. It gives hope to people who really don’t think there is any hope. When they hear that 20 million people were in the same situation as they were in, that there are a lot of different ways to get into recovery, and that there are a lot of very willing people who can help them do it, that instills hope at the individual, family and community levels, and hope is the one thing this field desperately needs.

Bill White: The current call to transform addiction treatment into recovery-oriented systems of care seems clearly an outgrowth of much of your work. Do you see this current focus on long-term recovery as a sustainable movement as we go forward?
Dr. McLellan: I do. I think recovery is first understood from a clinical perspective but what will sustain it in the public perspective are the financial, public health and public safety benefits. Sustainable recovery is what makes treatment and initial care worth it. Because of this, it follows that we need systems that will sustain the recovery process. Good treatment without the additional personal and social investment in sustaining continuing recovery is like having a damn good junior high school education—very important but not near enough to make it in the world. Just like education, we need to make it clear to individuals, families and the public at large that short term, quick fixes or simply physiological stabilization is necessary but not nearly sufficient to manage substance addictions.

But I think you are right to emphasize not just recovery but also the recovery system of care. We have always had charismatic individuals who could bring individuals into recovery—wonderful, but not adequate. We need systems that can be created and implemented and managed at the community level that will make recovery an expectable outcome of becoming sober and beginning a new lifestyle. I think it’s going to be one of the most cost-effective kinds of infrastructure development that we will do in this country.

As we begin healthcare reform, addiction treatment will be quite dramatically effected. Addiction treatment will be part of the rest of medicine. A very realistic question is what will happen to the federal Block grant? My own view is the federal Block grant ought to remain, and that it ought to be more directed toward building and sustaining recovery-oriented systems of care. As individuals get interventions and initial primary care through the mainstream healthcare system of the future—and that care is reimbursed through Medicaid—they will hopefully get a kind of care that they’ve never had before, but they won’t be cured. What they’ll need is places they can go following that initial
care where they can get recovery support services: peer support services, ­parenting skills, drug free housing, help with job transition or job placement, family support services. That’s what I’m hoping the Block grant will be used for.

Bill White: Many people working in the addictions field draw upon experiential knowledge related to their own personal or family addiction recovery experiences. You have been quite public about how addiction recovery affected your family. How has this experiential knowledge influenced your work in the field?
Dr. McLellan: Anybody that has a particular kind of a disease in their family is more acutely aware of the research in that field and new interventions or proposed interventions or medications, and that’s been the case with me. I have worked in this field for 35 years, studied all parts of it. Not only that, through my whole professional life, I have been surrounded by some of the best professionals in the field. But with all that going for me—knowledge, contacts and benefits that most Americans do not have access to—I found myself almost completely lost when members of my family first got into trouble. Because I am pain­fully aware of just how devastating addiction can be when it strikes your family, I have been working with lots of my colleagues for the past several years to translate what we are learning from science into practical knowledge and skills and supports that can be used by parents, families and communities. The good news is that lots of researchers in this field have turned to this type of translational activity, and there are an increasing number of parent groups and community organizations that are coming forward to demand better and more practical interventions and skill development.

Bill White: On Aug. 10, 2009, you were sworn in as the Deputy Director of the White House Office of National Drug Control Policy. What enticed you to leave the Treatment Research Institute and assume this role?
Dr. McLellan: I had had a fairly public loss in my family as a direct result of addiction, and that, combined with a very persuasive telephone call from Vice President Biden, led me to believe that maybe I should leave what I really loved doing and the people that I loved working with to see if I could help this administration make a contribution to the field at a policy level. I have to say it’s been a forced fit to put me in a policy environment—and this will come as no surprise to those who have worked with me in the past. I am an impatient guy, I favor a “ready—fire—aim” approach and government is much more of a “ready—aim—aim—aim . . .” environment. If you think research or clinical work requires patience, oh baby, try national budget-making, priority setting and consensus building in the context of pitched ideological battles, suspicious federal agencies and intensely invested private interest groups!

I do know that our Director, Gil Kerlikowske, has really improved the morale and function of ONDCP, and we have unprecedented support and involvement from the Vice President’s office. Day to day, it’s like walking through jello, but I think we have a shot at really helping people in the long run. I miss terribly the puzzles and excitement of investigation and discovery with my friends at my old job.

Bill White: Could you talk about how you have tried to influence the future of addiction treatment through this role?
Dr. McLellan: First, it’s clear that addiction at a policy level now is predominantly considered a criminal justice issue and thus managed by Departments of State and Justice, and by various law enforcement branches within those agencies. While they’re all doing a very good job, I was surprised to find that many of my colleagues in these agencies are unaware of the new developments in prevention, intervention, treatment and recovery. So, what I have tried to do is enhance their knowledge and help them with some new tools to add to what they are already doing. Thanks to the leadership of Gil Kerlikowske, I think we have already formed some really good functional partnerships between what is called the “demand reduction” side of addiction policy and what is called the “supply reduction” part of addiction policy.

Second, I have tried to move addiction integration forward. Despite the pervasiveness of addiction problems, they seem to be hidden under rocks, under rugs and behind doors. And yet, substance use problems affect every part of mainstream society from education to business to healthcare, ­criminal justice and welfare. Part of my role here has been to help those in policy positions see that they will never get a handle on healthcare reform, prison reform, sentence reform, welfare reform or educational reform if they don’t address substance use issues. My sinister plot for insinuating this issue into mainstream policy is to show them that attention to substance use issues within their own areas will help them develop far better policies and programs—that attention to substance use issues will help them reach their own goals in a much better way. We can add value to the rest of mainstream society. Substance use and addiction as an issue needs to be part of mainstream society, not shoved off to the side.

Bill White: You recently announced that you will be leaving ONDCP at the end of September. What factors led to this decision?  
Dr. McLellan: It really boils down to two things and neither of them have anything to do with either my current position or with the staff or leadership of ONDCP. I am honestly very proud to have served with these people and I can say they are as committed and diligent a group as I have ever worked with.  

The first factor in my decision is that I think much of what I can do has been done with the passing of the Parity and the Healthcare Reform Acts.  Thanks to the work of many, many people working in and with government, we have an unprecedented future for the substance use prevention, early intervention and treatment fields. That legislation will bring our issue directly into the mainstream of healthcare and while it will not be smooth or easy, addicted people will have opportunities they never have had. While the legislation, regulation and money to bring this came from the hard work of many in the federal government, the actual translation of how these opportunities will emerge will not come from federal government—it will come from the innovation and dedication from public and private groups in our industry. I want to be part of the innovation and creativity that I think will generate from within and outside our field over the next decade. New solutions will be developed by people already in—but also people that are now outside our field. Those ideas and opportunities will be tried at the community level and those that show benefit will become incorporated while old ways and new ones that don’t work will be discarded. I think that is the way it should be and I would like to play some part in those efforts at the grass roots.   

The second factor is simply that government processes do not suit my personality. I do not like the partisanship and institutional defensiveness that I see in so many places in government. Both these factors combine to turn issues where there is an empirical answer into a political or populous decision. The answer to “What does 2 + 2 equal?” does not take a committee or a vote; and regardless of public support or outcry—it is simply the correct answer. Researchers spend their lives looking for correct answers and I like industries and environments that foster that process.

Bill White: There is considerable interest in what activities you will pursue after leaving ONDCP. What are your immediate post-ONDCP plans?
Dr. McLellan: I really do not know what I will do when I leave. I want to take some time and think about things. I will not make any decisions for at least two to three months while I do some relaxing, reflecting and soul searching. I do not want to retire—but I do want to regroup and reorient. Government has disappointed me, but it has not decreased my optimism. There has never been a better time to be in this field and I look forward to finding a useful opportunity to contribute for another 10 years or so.

Bill White: Are there any final messages you would want to convey to frontline addiction professionals across the United States?
Dr. McLellan: My final message to counselors and other addiction professionals would be that your work is critically important. Our field has turned a corner, and we are beginning to become integrated into mainstream society. And it’s your work that is making that possible.

William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

Dr. McLellan served as Professor of Psychology in Psychiatry at the University of Pennsylvania, developed the Addiction Severity Index, authored more than 400 articles and chapters on addiction treatment, founded the Treatment Research Institute (TRI), and held the position of Editor in Chief of the Journal of Substance Abuse Treatment. He currently leads demand reduction efforts at the White House Office
of National Drug Control Policy (ONDCP).

The 500-member community of Alkali Lake is located in a remote area of British Columbia, about 35 miles from Williams Lake in the Cariboo Region of the Province. It is significant in the world of addictions recovery because of a sobriety movement that began there in the early 1970s, when Phyllis Chelsea made the decision to stop drinking after her daughter refused to come home with her. Phyllis sought help from an Alcoholics Anonymous (AA) counselor in Williams Lake, and she was soon joined by her husband, Andy. The two of them had been sober nearly two years when they welcomed the next member. From those humble beginnings, Alkali Lake transformed itself from a community devastated by alcoholism to a true recovery community that would ultimately affect aboriginal communities around the world.

A 1986 film, The Honour of All, covers the sobriety movement in the Alkali Lake community from 1971 to 1986, ending with an international conference on recovery hosted at Alkali Lake. Alkali Lake’s struggle, to free itself from alcoholism and to heal its traumatic history of genocide and oppression, continues to this day, and because of this, the ­community’s sober leadership maintains a long term commitment to encouraging traditional ceremonies, 12 Step recovery groups and providing professional therapy and workshops for community members. This article recounts the 10-year involvement of a non-Native addiction professional in Alkali Lake and offers some lessons learned that might be of benefit to counselors working with Native communities.

Early involvement in Alkali Lake
The many recovery support activities within Alkali Lake, developed over the course of the past 37 years, created an environment in which a non-Native therapist could become part of this community.

I went to Alkali Lake with some history of multicultural experience that prepared me for the work there. I was born and reared on a ranch near Silver City, New Mexico.  I grew up speaking Spanish and also knew Apache and Pima families. Both my parents had bilingual/bicultural experience. From 1986 through 1988 I was enrolled at the University of Iowa in a Master’s level program for addiction counselors that included a bilingual/bicultural certificate in Spanish, as well as a focus on Native American culture. I also had been playing the flute music of the Andes Mountains Indians and Native Americans since 1980.

I first visited Alkali Lake in 1999 as a guest speaker at its annual recovery celebration event. Meeting some of the people from The Honour of All was thrilling, since I had been showing the film to my patients for years. I continued to attend Alkali Lake’s yearly recovery celebration. Each time I spent the week leading up to the event helping the community members with preparations, I learned more about the community and its ongoing struggle to keep the sobriety movement going.  We also had visits from Alkali Lake Band members to the Betty Ford Center (BFC) Professional-in-Residence (PIR) Program in 2000 and 2001. Those visits helped many of my colleagues and my supervisor, David Burgdorf, all of whom had seen the film, become enthusiastic with regard to developing a serious relationship about sobriety with this First Nations community. There was hope that these encounters could help increase the BFC staff cross-cultural competency and help us be of better service to local tribal members.

I returned to Alkali Lake in 2004 for their annual recovery celebration. The week-long preparation leading to the Round-up was an opportunity for me to revisit a challenge I had faced before. There is considerable difference between “Native time” and Seme7 (pronounced: seh’ meh huh) time.” There also is a difference between Native values and non-Native values around organizing and accomplishing. I could see on Monday all the things that needed to happen by Friday and had what I thought were some excellent ideas for making the celebration event better and more efficient. Ken Johnson and other event organizers were to meet me at the powwow arbor at 2:00 pm to get started. At 4:00 pm, nobody had yet arrived and my frustration level had reached an “8” on a scale of “1-10.”  I couldn’t really carry out the things I believed needed to be done because I lacked tools and support.  About 7:30 pm, four or five cars pulled in and community helpers piled out and started doing a multitude of things that weren’t even on my list. This pattern continued throughout the week and when Friday came around, everything seemed to turn out beautifully except that very little on my list had been accomplished. Those who attended, including me, had transformational experiences, celebrated sobriety and made a commitment to return again next year. How could this be?

I felt embarrassed that I had been so arrogant and that the event was quite phenomenal, despite my concerns and plans. This seems to be a common issue for non-Natives serving in First Nations and American Indian Communities. We try to impose our values and expectations in a variety of ways. Many get frustrated, give up and move on.

With the retirement of Dr. Tony Stickle, who had served as a therapist for members of the Alkali Lake community, I was invited to BFC to serve in this role. Beginning in August 2005, I began making monthly visits to Alkali Lake. The challenges were numerous, including: the long distance travel required to get to the community; absence from my family; and my other work responsibilities at Betty Ford. There was also the challenge of attempting to follow in the footsteps of retired Dr. Stickle, who had become a beloved member of the community during his years of service there.
A number of outreach efforts were made to help the community accept and use me as the new therapist. My visits were announced on the radio, and flyers were posted at the Esketemc Health Centre. I also went out into the community to introduce myself; this process was slow and I sometimes wondered if it was going to work.

In addition to individual sessions, I offered a 12-hour family workshop during some of my visits; art therapy groups for women; a week-long men’s workshop; and within the last year, I have been working with students at the Sxoxomic School teaching them Native American flute as a vehicle of alcohol and drug use prevention. This position has been multifaceted and I have really had to get to know the community and its needs to learn how to be of optimal service.

After my first year, I had a number of experiences which let me know that I was gaining the acceptance of the community. One happened on a visit to a band member’s home when the four year-old granddaughter and four of her friends saw me coming and all began running towards me with hands out-stretched yelling, “Patrick, Patrick, hugs, hugs, hugs.” Another happened as we were preparing for the 30th Annual Alkali Lake recovery celebration event in 2006. I saw my supervisor, Irene Johnson, sitting near a camp fire talking with five or six other community members. I approached the group and noticed the fire was surrounded by two concentric circles of patterned, interlocking bricks to make a fire pit. I commented, “Wow, awesome,” and the group burst into laughter some falling and rolling on the ground. I was amazed. What could be so funny? I asked Irene about it. She laughingly said that she had just finished telling the group that the Seme7 (non-Natives) would see the patterned bricks of the new fire pit and say, “Wow, awesome,” I had made her prediction come true only moments after she foretold it. I laughed at my comment with the rest of them and said, “And I thought I was making such great progress at becoming an Indian.” The group burst into laughter once again.

Since many of the clients had sobriety and trauma recovery experience, they were able to talk about the childhood trauma they experienced of physical, emotional and sexual abuse at home and at the residential schools. I was hearing things that were so unimaginable that I needed to be defused and debriefed upon my return home. The truly amazing thing to me was that these individuals had survived, and now, because of their sobriety, were continuing to recover.

One of the challenges in doing this work at the current level was for the BFC administration to see value in the work. In 2006, I invited Dr. Garrett O’Connor, the Chief Psychiatrist at BFC and Mike Neatherton, Chief Operating Officer, to join me and some Betty Ford alumni for the 30th Annual Alkali Lake celebration event. There were 12 of us from BFC and each had a profound, transformational experience. From that time, support at the BFC grew for continuing to work with and support the recovery movement at Alkali Lake.

I was introduced to the Sweat Lodge Ceremony in 1999 by Freddy Johnson who said: “I’m keeping the heat low for the Californian.”  I remember coming out of the lodge after the first round, as is the practice at Alkali Lake, and feeling quite certain I would soon die from the heat. With the support of others, I was able to stay in the moment, one breath at a time and I survived my first sweat. I have since become a regular participant.
I joined the Esket community in fasting on the mountain in 2005 and 2006, an experience that challenged me to grow spiritually by facing my fears and acquainting myself with the Creator as It manifests in all the forms of Nature. Prior to my first experience on the mountain, I jokingly said to Freddy Johnson, “This can’t be good for you, you know, to expose yourself to the elements for four days and four nights without food or water.” He laughed and said: “Well, I don’t know, we’ve been doing it for over 10,000 years and it hasn’t hurt us so far.”

In June 2007, I was blessed with the opportunity to attend parts of the four-day Unity Ride. This annual four-day horse journey began in 2000 as a way to help heal the wounds of the 1995 Gustafsen Lake Standoff (http://en.wikipedia.org/wiki/Gustafsen_Lake_Standoff). This siege lasted over 30 days, and involved 14 indigenous ­people and four non-natives in a dispute over sacred Sun Dance lands. According to Alkali Lake Chief, Charlene Belleau, members of the Alkali Lake Band Council were involved in ­negotiations between the Royal Canadian Mounted Police (RCMP) and the ­protesters.

During the event in 2007, RCMP officers made an official apology for their involvement in the Residential School saga. When the apology was made, tears were flowing throughout the crowd. It was a profound and healing experience. This eventually led to the official 2008 Canadian Government apology.

Another component of my personal/professional transformation has to do with music. In learning some of the sweat lodge songs and working with Freddy Johnson and Arthur Dick, I began to see how music could be used to inspire spiritual awareness. This led me into my first composition, a musical exploration of the 12 Steps, Recovery Spirit, which was released in 2002. The 2002 release was followed by two more 12 Step CDs in 2006 and 2008. This transformation has helped me share the 12 Step experience both with Natives and non-Natives, using music that reaches deep into the soul where I find the 12 Steps and the Red Road (native spirituality) come ­together.

My experience at Alkali Lake has changed me in a professional, as well as personal sense. I am grateful to the people of Alkali Lake who have been very patient with me as I learned to love and respect their culture and their ways.  I’ve learned that through loving and respecting First Nations’ individuals, families and whole communities, I can be helpful, even though I’m Seme7 (non-Native), in ways I wouldn’t have thought important prior to my cultural sensitization. At times, just being present to help out in any way needed was adequate.

I am grateful to BFC and Betty Ford Institute for seeing the potential in this assignment. We are offering support to a recovery movement which has had a positive impact on countless Native communities throughout North America and is also an inspiration in Australia. The entire culture of BFC has been affected in a very positive way through its involvement with the Alkali Lake community. Because of the relationship with Alkali Lake, many new doors are beginning to open for BFC and Betty Ford Institute to be of service in various cultures.

Patrick Haggerson is a Training Specialist/Therapist at the Betty Ford Institute.

References and ­Recommended Reading
Arbogast, D. (1995). Wounded Warriors A Time for Healing. Omaha, NE: Little Turtle Publications.
Abbott, P.J. (1998). Traditional and western healing practices for alcoholism in American Indians and Alaskan Natives.  Substance Use and Misuse 33(13), 2605–2646.
Chelsea, P and Chelsea, A. (1985). Honour of All: The People o f Alkali Lake.  (video documentary by P. Lucas) British Columbia, Canada: The Alkali Lake Tribal Council.  
Cohen, K. (2003). Honoring the Medicine: The Essential Guide to Native American Healing. New York, NY: Random House Ballantine Publishing Group.
Coyhis, D.L.; White, W.L. (2006). Alcohol Problems in Native America: The Untold Story of Resistance and Recovery—“The Truth about the Lie.”Colorado Springs, CO: White Bison, Inc.
Coyhis, D.L. (2009). Understanding Native American Culture, Second Edition. Colorado Springs, CO: Coyhis Publishing and Consulting, Inc.
Guilory, B.M., Willie, E. and Duran, E. (1988). Analysis of a community organizing case study: Alkali Lake. Journal of Rural Community Psychology 9(1), 27–36.  
Haggerson, P. (2002). Recovery Spirit (music CD) La Quinta, CA: CTC Music Productions.
Haggerson, P. (2008). Recovery Spirit 2 (music CD) Indio, CA: RuffJazz Records.
Howorth, C.J., Stiffarm, L.A., Webster, D., Webster, K. (1992). Sharing, Caring and Consequences: A Study on Sobriety and Healing at Alkali Lake Reserve. Ottawa, Canada: HER MAJESTY THE QUEEN IN RIGHT OF CANADA.
Jilek, W. (1994). Traditional healing in the prevention and treatment of alcohol and drug abuse.  Transcultural Psychiatric Research Review 31,219–256.
Sue, D.W. (1981). Counseling the Culturally Different Theory and Practice. New York, NY: John Wiley and Sons, Inc.
Taylor, V. (1987). The triumph of the Alkali Lake Indian band.  Alcohol Health and Research World Fall, 12(1), 57.
Willie, E. (1989) The Story of Alkali Lake: Anomaly of community recovery or national trend in Indian Country? Alcoholism Treatment Quarterly 6(3–4), 167–174. 

Editor’s Note: This article is comprised of material from the author’s book,
Erotic Intelligence: Igniting Hot, Healthy Sex While in Recovery from Sex Addiction.

Hot, healthy sex comes from a mutual commitment to recover from sex addiction and build a healthy relationship. Yet knowing what lays the foundation for this kind of addiction is critical in rebuilding neural pathways that make having hot, healthy sex possible. 

It’s important to realize that sexual addiction resides in the brain, not in the vital parts. During the first two years of one’s life, eye contact, facial expression, gesture, tone of voice, touch, movement and empathic interactions profoundly affect the development of an infant’s right brain—the side that includes a complex neural network connected with emotions and moods. 

In addition to functions such as processing social and emotional interactions, learning and memory, reward and pleasure, judgment and morality, the right brain is also primarily involved in an infant’s ability to form attachments. It is also the area of the brain that regulates one’s emotional and physiological states. “Regulating states” or self-regulation refers to an ability to be aware of, control and monitor emotional reactions, impulses and behavior. This affects one’s ability to repair emotional distress, usually by taking control of and renegotiating the surrounding environment. It often takes the form of seeking comfort from another, meaning that a child who has learned to successfully self-regulate and/or seek co-regulation from another responds well to life and adjusts to what doesn’t work.

How sex addicts regulate these states differs from healthy self-regulation. Most likely, their self-regulation skills were impaired or absent in childhood. It’s common for them to have limited ability to control their behaviors. For them, the most frequent source of disrupted behavioral patterns stems from emotional disconnection modeled in their ­families of origin—often starting in ­infancy.

Road to recovery
For sex addicts to experience an intense high, requires more and more stimulation over time. Dopamine—the body’s chemical reward transmitter—is what raises the tension from “I want it” to “I’ve got to have it.” When an addiction hijacks the dopamine system, it’s like receiving the pleasure of winning a race without the effort of running; addicts experience a high they didn’t work for. Before long, addicts’ brains become sensitized to the experience, so they crave more and seek to get more.

On the road to recovery, sober sex addicts can use this knowledge to “cut new grooves”—that is, they can find ways to curb their impulse for “more.” One way is by choosing new goals for achieving pleasure within a safe environment. That leads to carving out new behaviors that will eventually boost their erotic intelligence and bring them closer to true ­intimacy.

Like other addictions, recovering from sex addiction involves learning new ways to cope with the world, and changing certain undesirable behaviors. For example, addicts can decide to have honest dialogues with their spouses and repeat that action again and again in a comfortable, familiar environment. Doing this causes their neural networks to gradually light up and new “grooves” to be cut.

This process of cutting grooves can be understood by examining how toddlers learn. To acquire new skills like crawling and walking, they place their full attention on interacting within their safe environment. They look to their caregivers for reassurance and approval to know they are on the right track. These actions get repeated again and again, thus cutting new grooves in the right hemisphere of the brain so new behaviors can eventually happen at will. However, many things can disrupt their safe environment during this learning phase. Parents spanking them or yelling at them rocks that feeling of safety and puts them on alert. Their attention gets divided between their innate need to learn and an urgent focus on impending danger. Similarly, when those with addictions come out of their isolated environments, they need to put time and effort into changing the patterned impulses within their brains to address perceived danger.

Why would sex addicts take on the challenge of “cutting new grooves” and changing their behaviors? Because they have decided it’s time to “grow up”; they want to emerge whole from any lingering adolescent sexual behaviors that are hurting them, and to strive to “unfreeze” existing patterns. More important, they desire to “be present” in their intimate relationships thereby creating new foundations of healthy attachments and bonding in sexual relationships that are free from previous addictive behaviors. Hot, healthy sex based on true intimacy is the reward.

Successful infant attachment and ongoing bonding allow for one’s emotional qualities to expand when they engage with a partner. Children who have developed healthy personalities learn to be comfortable striking out on their own while taking risks and experiencing logical consequences. The more they explore, achieve and succeed, the more secure and assured they feel throughout life. As adults, they naturally become autonomous, feel competent in their interactions and confident in their decision-making.

Attachment feeds autonomy in this way. People who are autonomous seek the connection and comfort of attachment with their partners. They know who they are and allow the same autonomy for their partners. They experience the human bonding process as growing into independence and being capable of negotiating people and tasks successfully.

Yet, here’s the paradox. People do not exist independently; they seek a heart-to-heart relationship so they can know themselves more intimately. That’s where sex comes in. Sexual energy between two people is a primal force ­comprised of power (energy that moves toward another) and virtue (knowing the energy between the two is right). When they come together intending to experience attachment and autonomy, these energies create a balance between them. As the Tao Te Ching states, “To­getherness includes separateness. ­Separateness includes togetherness. Within each there is the other.”

Those who become sex addicts use sex as a way to exert power and control over their situations. By comparison, healthy people feel the true power of their sexuality when they understand how to change and grow honestly. Achieving and sustaining their sexual potential requires staying current with what’s true about their changing sexuality, bodies and sexual interests. From there, they willingly commit to sharing those changes with their partners. They turn to active (not passive) coping skills to make the changes they desire.

Active coping skills include seeking support or solace from others and generating possible solutions. An example would be going to 12 Step meetings and reaching out to people in the program. Active coping also includes self-regulatory, solitary activities, such as journaling, reading, meditation and contemplation. In contrast, passive coping skills include escape, avoidance, chronically going into sexual fantasy, masturbating in secrecy, isolating and withdrawing from others. Passive coping can engender helplessness and/or hopelessness.

Addictive versus healthy sexual behaviors
Ultimately, the relationship game is about people feeling okay about themselves. They have to understand that no one—not their partners, nor their counselors, nor anyone else—can “save” them. Whatever goes wrong is up to them to change, including adjusting their primary learned responses that don’t work in a healthy way.

Instead of repairing their old disconnecting patterns, most addicts ­replace their partners—and go on to reenact their unhealthy patterns.
Ironically, sex addicts who have had an astounding number of varied sexual experiences know little about relational sex. Their ideas can be ritualistic, simplistic and even adolescent due to engaging long-term in stunted arousal patterns. Understanding what healthy sex can be has alluded them.
Having a healthy sexual relationship is perhaps best defined by what two people consider an ideal sexual state; it’s knowing the functions of the sexual anatomy for both genders; it’s cultivating healthy sex habits; accepting oneself without shame and blame; and being aware of the roles that masturbation and fantasy play. Overall, it’s focusing on positive sexuality.

The chart shows “at a glance” the differences between sexual behavior that’s healthy and behavior that characterizes addictive sex.

      Addictive Sex                                Healthy Sex

 Adapted with permission from Don’t Call it Love, by Patrick Carnes, Ph.D. © 1991

When sex addicts are no longer driven by the chemical high of falling in love or chasing orgasms, intimacy and love become a choice. Here’s how ­behavioral changes can happen:
• Changing old habits requires choosing a specific target behavior and repeating it in a comfortable and familiar environment. This might mean taking time to look into a partner’s eyes during intercourse, even though it could elicit discomfort at first.
• The new behaviors change from first-stage meaning (i.e., following a plan to stay sexually sober) to second-stage meaning (i.e., integrating a full range of sexual behaviors that are relational).
• New behaviors require cutting new grooves or opening neural pathways. Cutting new grooves requires processing any tension felt around establishing new ­patterns.
• All of the strategies used to develop richer relationships with partners have one goal: to make new behavior patterns comfortable and familiar.
• Intimate sex relies on self-love, nurturance and the willingness to feel deeply. Being vulnerable and fully present lays the path to intimacy and erotic intelligence.
• Healthy sex requires the four cornerstones of intimacy—self-knowledge, connection and ­comfort, responsibility with discernment and empathy with emotion—to be in play. It’s wise to place the most emphasis on the fourth one—empathy for one’s partner. 

Intimacy means feeling so comfortable with another that experiencing the closeness, the heart bond, is valued more than any “high.”
The road to recovery calls for a greater understanding of true intimacy and its components, which I call the four cornerstones of intimacy.
The first cornerstone is Self-Knowledge, which requires feeling comfortable alone and with one’s partner on a greater level than before. Both parties become more willing to move through their own issues or tolerate unpleasant situations so they can change and grow. Acceptance implies accepting oneself and one’s partner as they are while coming to agreements about values, choices and solutions to ­problems.

The second cornerstone is Comfort and Connection. For couples, this means establishing patterns for co-regulation with each other. Every bonding ritual creates newness and helps the neural wiring process. Connection includes the attachment process at the biochemical level through which people feel safer and more secure with their partners. Paradoxically, this safety and security lays a foundation to take sexual risks that can provoke anxiety—a component that’s also necessary for growth and change.

The third cornerstone, Responsibility with Discernment, holds both partners accountable for a certain level of maturity, such as managing moods and honoring commitments. They agree to remain present and conscious with themselves and each other. They show their commitment through actions, not promises. They earn each other’s trust by being trustworthy; they earn each other’s love by being loving. And they simply allow no room for blame.

Empathy with Emotion is the fourth cornerstone of intimacy. Empathy requires an ability to recognize another person’s thoughts, feelings and moods. This is useful along with “role taking,” which is seeing the world from another’s perspective. Empathy is usually present in self-revelation. This allows partners to be receptive or expressive in their interactions—as Justine’s and Brian’s story reveals.

For years, Brian tolerated Justine’s lying, cheating and angry outbursts. Finally, Brian told her he felt battered and could no longer go on as they were. Justine went into recovery at this point, and by the conclusion of one year of sexual sobriety, developed empathy for Brian. She no longer believed the story she told herself about “being a good person” to justify her actions. She also saw how much Brian had sacrificed during their 10-year relationship and the toll it had taken on his career and psyche.

Not only did Justine make amends, but she changed how she managed her business, adjusting her work hours and leaving earlier so she’d have more time at home. Justine developed compassion for how isolated Brian had felt from his friends and family as a result of her addiction. Showing him empathy opened a door for him to grieve his losses and begin healing. This started them on the pathway to erotic intelligence and healing as a couple.

Once sex addicts have broken through old patterns and cut new grooves for healthy relationships, experiencing intimacy becomes the reward. They find new ways to know their partners, share struggles, and ask for mutual needs to be met. This journey proceeds from healthy sex to intimate sex, and then to erotic sex—all the while growing toward a spiritual base in the relationship.

Ultimately, recovering sex addicts look beyond true intimacy, desiring a spiritual, transcendent experience at the end of the pathway.

Alexandra Katehakis ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) is a licensed Marriage, Family Therapist, Certified Sex Addiction Therapist, Certified Sex Therapist and Supervisory Consultant to the International Institute of Trauma and Addiction Professionals (IITAP). She has extensive experience working with a full spectrum of sexuality—from addiction to problems of sexual desire and dysfunction for individuals and couples. Her latest book is Erotic Intelligence: Igniting Hot, Healthy Sex While in Recovery from Sex Addiction.


Resources
National Therapy Resources Center for Healthy Sex: www.thecenterforhealthysex.com
Telephone: (310) 335-0997
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Offers an Intensive Out-Patient Program (IOP) for treating issues of sexual addiction and ­sexuality.

Sexual Addiction Resources/
Dr. Patrick Carnes: www.sexhelp.com
Offers books, exercises and referrals online from the leader in this field.

The Society for the Advancement
of Sexual Health (SASH): www.sash.net
Telephone: (706) 356-7031
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Provides resources and information on addiction therapists, treatment centers and support groups.

American Association of Sex Educators,
Counselors and Therapists (AASECT): www.aasect.org
Telephone: (804) 752-0026
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Provides resources/information on sex therapy and how to locate a sex therapist.

American Association of Marriage, Family Therapists (AAMFT): www.aamft.org
Telephone: (703) 838-9808
Offers resources/information for couples and ­families and how to locate a Marriage, Family Therapist.

International Institute for Trauma and Addiction Professionals (IITAP): www.iitap.com
Telephone: (480) 575-6853
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

IITAP offers Certified Sex Addiction Therapist (CSAT) designation.
12-Step Program for Couples
Recovering Couples Anonymous (RCA): www.recovering-couples.org
Telephone: (510) 663-2312

12-Step Programs for Sex Addicts
Sex Addicts Anonymous (SAA): www.sexaa.org
National: (800) 477-8191
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Sexual Compulsives Anonymous (SCA): www.sca-recovery.org
National: (800) 977-4325 (977-HEAL)

Sex and Love Addicts Anonymous (SLAA): www.slaafws.org
National: (781) 255-8825
   
Sexaholics Anonymous (SA): www.sa.org
National: (866) 424-8777
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12-Step Programs for Significant Others
S-Anon International: www.sanon.org
National: (800) 210-8141 or (615) 833-3152
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Codependents of Sex Addicts (COSA): www.cosa-recovery.org
National: (763) 537-6904
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CO-Sex Addicts and Love Addicts Anonymous (COSLAA): www.coslaa.org
Help Line: (860) 456-0032
 

The implementation of Evidence-Based Treatment (EBT) is increasingly being encouraged by funders and considered best practice by many treatment professionals and accrediting bodies. There are now several EBTs that have been developed, tested and found effective with adolescents who have substance use disorders (Dennis et al., 2004; Springer & Rubin, 2009; Waldron & Turner, 2008). However, most of the EBT manuals that have been developed are designed for outpatient or community-based service delivery. Little has been written about how these treatments might be implemented in existing adolescent residential treatment programs. Moreover, many residential treatment professionals learn about these EBTs at conferences or by reading the literature, but find almost no information to help them tailor these approaches to residential settings.

In the United States, most adolescent residential treatment programs use a modified version of the Therapeutic Community (TC) approach (Morral et al., 2003; Shane et al., 2003). The TC approach was originally developed by recovering individuals for adults, and modified to enhance its applicability for adolescents. Some of the hallmarks of this approach are phases of treatment that participants progress through based on their behavior in treatment, and an expectation that individuals will change in multiple life areas through what is learned from their peers in the community setting. As they progress through treatment phases, individuals earn additional privileges. Conversely, for rule infractions, individuals can lose privileges or receive punishments. Adaptations for adolescents have included: the use of less confrontation; increased emphasis on education; more supervision; and greater involvement of family (Jainchill, 1997). Since TC approaches have been so dominant for residential treatment, most residential programs for adolescents probably employ some of these components and elements of 12 Step approaches, and these sometimes may appear incompatible with EBTs.

It is no small task to change any existing treatment program, and residential treatment systems present some unique challenges. The biggest difference between outpatient treatment and residential programs are the number of hours that youth are involved in services. In residential treatment, staff are responsible for youth 24 hours a day and must constantly monitor them and ensure they are engaged in productive and therapeutic activities for the requisite number of hours each day that are typically prescribed by state licensing. When programs have been in existence for a period of time, staff at all levels develop routines and can be resistant to change. Residential programs, in particular, employ a large number of shift staff who do not have the academic training or experience of licensed clinicians, so management must evaluate appropriate expectations for their skill level and determine how best to train them in new skills. Moreover, it has been documented that clinical staff in the substance use treatment field have high turnover rates, and these rates are probably highest among paraprofessional staff, which contributes to the difficulty of quality staffing for 24-hour programs. Finally, since most EBTs are not going to fully replace an existing approach in a residential treatment program, consideration must be given to how the new EBT will integrate with and enhance the treatment experience.

Adolescent Community Reinforcement Approach
This article describes a case study of the implementation of the Adolescent Community Reinforcement Approach (ACRA) (Godley et al., 2001) in an existing residential program. A-CRA is a treatment that is based on the theory that it is possible to help individuals change their environment to one that is reinforcing without the use of alcohol or other drugs. Therapists are trained to acknowledge that adolescents begin using these substances because they find their use and the associated socialization reinforcing. A-CRA clinicians work to help individuals identify other reinforcers and learn ways to access them. Adolescents also learn to identify antecedent behaviors that precede substance use and other problem behaviors, and how to interrupt these behaviors so that they do not lead to substance use. The approach emphasizes positive interactions during therapy, which is a developmentally more appropriate approach with adolescents than confrontation.

Clinicians are trained to draw from a menu of 17 procedures—many of which behavioral or cognitive behavioral—that can be used based on issues presented during a therapy session (e.g., functional analysis of substance use, problem solving). One of these procedures is a one-page Happiness Scale, which allows participants to indicate their happiness in multiple life areas on a 1 to 10 scale. This exercise leads to another procedure, during which the clinician helps the adolescent develop goals in areas with lower ratings that are specific, stated positively and measurable, and emphasizes that treatment is more about helping these young people with multiple problems find ways to enjoy life, and not just about quitting alcohol and drug use.

Description of the Existing Residential Program. The residential program in which A-CRA implementation took place is a 54-bed program that serves adolescents from Illinois between the ages of 13 to 18. It has been in existence since 1985, and is separated into three units: a female unit and two male units (one of which is a specialized long-term unit for more chronic or behaviorally disordered young men). The program’s approach has evolved with multiple components including: 12 Step groups; skill building groups; individual, group and family counseling; and a token economy system used to reinforce positive behaviors and discourage negative behavior/rule infractions. Like the TC model described above, adolescents progress through different stages of treatment. Adolescents also can attend an onsite school.

Each unit is staffed with clinicians who are either licensed (LCPC or LCSW) or certified by the State of Illinois as alcohol and drug counselors. Clinicians have primary responsibility for the treatment of five to eight individuals and work varied hours, including some evenings. These clinicians provide ongoing assessment of individual needs; individual, group and family therapy; ­discharge planning; and some case management activities, such as maintaining contact with referral sources, probation officers, outpatient counselors and schools. The shift staff are called residential counselors (RCs) and their job duties include: serving meals; making sure that adolescents attend treatment groups on time; checking chore completion; facilitating certain didactic groups; monitoring the adolescents at all times; providing crisis intervention when professional staff are not available; and collecting urine screens. Each unit has a clinical supervisor who hires, trains and provides regular supervision to unit staff. There are additional staff who support the core staff, including curriculum specialists, recreation specialists, nursing staff and a consulting psychiatrist who provides ongoing psychiatric evaluation, consultation and medication management. An associate director coordinates all three units, and a director oversees both residential and outpatient services.

Motivation for Change. The impetus for considering the adoption of a new EBT was quality assurance data that revealed the residential program was experiencing difficulty engaging and retaining young women. For three consecutive years, the young women’s unit had high rates of premature discharges, with many of these individuals returning to juvenile court/detention. During the year before A-CRA implementation, the percentage of young women successfully completing the program decreased from 45 percent for the previous year to 42 percent, and the average length of stay was 35 days (for a program designed as a minimum 90 day). Furthermore, management staff felt the existing treatment approach was focused too much on punitive consequences and not enough on rewarding positive behavior. For example, the token economy system was primarily used to mete out punishments, rather than to shape healthier and positive recovery-oriented behaviors. Since Chest­nut has a research and training division that had led the adaptation and evaluation of A-CRA and was training Center for Substance Abuse Treatment (CSAT)-funded adolescent treatment providers around the country in this approach as part of the Assertive Aftercare and Family Treatment initiative (AAFT; TI-06-007), it was a logical EBT to investigate. Resi­dential treatment staff reviewed the treatment manual (Godley et al., 2001) and the research supporting it (Dennis et al., 2004; Slesnick, Prestopnik, Meyers & Glassman, 2007), and made the decision to pursue staff training in the model for the residential female unit.

Assessing Readiness and Commitment to Change. The decision to adopt a new EBT, because it seems like a good idea, is the first step in a long journey. The next steps are to understand as fully as possible what will be involved during the process of learning and implementing the intervention, and then ­assess program readiness and commitment to adopt the intervention. In order to assess readiness and commitment, there are a number of factors that must be considered, including: how the EBT will be integrated into the existing program; how quickly changes will be implemented; expectations of different types of staff (e.g., primary therapists, residential counselors); what the training process will entail; whether there is an organization level commitment to sustaining the training and implementation effort; how fidelity will be maintained; and how training will be sustained on an ongoing basis.

These questions were discussed during meetings with the program director (M. Kenney), key staff and one of the model developers (S. Godley). The clinical management team decided to add A-CRA to the existing treatment model by increasing the number of individual sessions clinicians provided to adolescents and to train RCs in strategically selected procedures, based on what would be most helpful to them and the adolescents in the residential program. After learning about the rigorous training and certification model (described in Godley, Garner, Smith, Meyers & Godley, in press), the program director made a commitment to adhere to these expectations and implement the model with fidelity to the research-tested manual. Over time, additional plans were made to address sustainability.

Implementation Begins. The decision was made to implement the EBT gradually because experience with another implementation effort had shown that attaining buy-in from strategically chosen opinion leaders helped facilitate the implementation process. Initially, one clinician and the female unit’s clinical supervisor attended training and began the A-CRA dual (clinician and supervisor) certification processes. Clinician certification is based on A-CRA expert reviews of therapy sessions, which are recorded with a digital recorder and uploaded to a web-based system. Experts then listen to the session and rate clinicians on the components of each procedure they attempt to implement and write narrative comments about how to improve their implementation (see Godley et al., in press). The hope was that the first clinician would like the model, training and certification experience, and would then become an internal champion for the model and influence other staff positively. The initial feedback from this clinician was very positive, and she perceived that her clients were responding very well to her use of A-CRA procedures, in short, supporting how management believed A-CRA would enhance ­treatment and providing the confidence to move forward with the rest of the young women’s unit staff. The remaining clinicians were trained and expected to become certified in 19 A-CRA procedures because management felt it was important that participants receive all of these procedures during their treatment episode.

The decision also was made that shift staff or RCs would be expected to become certified in three A-CRA ­procedures that were especially relevant to issues that routinely arose on the residential unit, often in the late evening hours when other staff were not present. These procedures were communication skills, problem solving and anger management. In this way, the RCs were able to help adolescents practice their skills numerous times in real-life situations on the unit. Thus, problem interactions between the young women on the unit or between adolescents and staff often became opportunities for practicing positive life skills, rather than situations in which negative consequences were assigned.

Management staff were instrumental in encouraging both licensed clinicians and RCs to practice procedures with each other and record sessions using procedures with adolescents. Certain staff members (especially those who were not trained with this type of feedback) were reluctant or fearful of recording their work because they were anxious about receiving the narrative feedback and an “evaluative” score of their work. To address this barrier, management staff were liberal with praise for progress and began offering small incentives for staff who recorded sessions. Once staff received their feedback from the expert reviewers and discussed it with their supervisor, the positive way in which feedback was given helped lessen their anxiety. Interestingly, although many staff felt that the clients would be uncomfortable with the digital recording, this has not been the case. In more than two years, there has never been an adolescent in the residential programs who has refused to be recorded.  
Implementation Benefits. Overall, interactions between treatment peers and staff have become more positive, and they have a common language to use in certain challenging situations. For example, talking about an “Understanding Statement” (a component of communication skills) or “Cooling down” (a component of anger management) is commonplace. Since the model emphasizes a positive approach; focuses on each individual adolescent’s reinforcers; and encourages the use of praise, adolescents feel good about their time with clinicians and RCs. One example of changes related to in­creasing the availability of positive interaction is that prior to implementing A-CRA, the only attention that adolescents would receive after a urine test was if they tested positive for drugs; and this attention typically came with negative consequences attached. Adolescents are now praised for submitting negative (clean) urine screens (particularly when they return from passes to their home community).
Another benefit is that by incorporating RCs appropriately into this implementation effort, their training has become more systematic and focused to their role, and they have been able to learn important clinical skills. They are now seen more as part of the clinical team, and the adolescents appear more apt to respect their experience, knowledge and role on the unit. An added benefit is that several of the RCs have begun ­certifi­cation in procedures outside of Communication Skills, Anger Manage­ment and Problem Solving. The process has helped identify individuals who demonstrate potential to become clinicians, and it gives them opportunities for continued professional growth. Adolescents are given positive rewards including praise and behavior tokens, which can be ex­changed for privileges like making a phone call, passes to leave the unit, or promotion to new levels. When participating in sessions with the RCs, they will often request to have a session to practice A-CRA related skills. The young women’s unit also has incorporated A-CRA procedures into its level system, identifying specific procedures that are appropriate, considering the level that the adolescent is at in his/her treatment experience. For example, prior to beginning overnight passes to their home environ­ment, they should have p­articipated in Refusal Skills and Relapse Prevention as well as Sobriety Sampling.

Maintaining Model Fidelity. Maintain­ing fidelity is an important aspect to implementing any EBT. To emphasize the importance of attaining certification and maintaining model fidelity, policies have been written regarding these expectations, and job descriptions were re-written accordingly. By doing so, the management staff have demonstrated that competency in A-CRA delivery is just as important as other job duties like completing clinical records. Addition­ally, each month management staff produces and reviews a management report that provides data about where their staff are related to the certification process (e.g., number of digital sessions uploaded to the web tool, number of procedures passed), as well as competence shown during fidelity checks for those already certified. Clinical supervisors work with staff who are reluctant to record, or who are struggling to pass procedures during supervision sessions using a combination of review and role plays. It is important to note that a few staff in place at the beginning of the implementation project have not been able to adapt to the model, and if they could not, then objective criteria (based on reviews of in-session behaviors and progress in the certification process) were used to determine their continued appropriateness in their positions. Finally, quality improvement data suggested that retention on the unit had increased. In the year after implementation, for the first time in three years, the percentage of successful completions increased, from 42 percent in the prior year to 55 percent; and the overall length of stay increased in the year following implementation from 35 to 49 days across all discharge types (As Planned, Against Staff Advice (or AMA) or Administrative Discharge).

Sustainability and Next Steps. Typi­cally, funds are needed to support the training and implementation effort (e.g., training workshop, session ratings, management report production, coaching). Since the residential program was in the same organization as the national trainer, some in-kind services were provided, but these services were not going to be available on an ongoing basis. Since no new funds were available to help with sustaining the model, the implementation team had to be creative in developing mechanisms to sustain the training and certification process. Early on, a decision was made to train an individual who worked the night shift in how to rate the three procedures that RCs were required to learn. This individual had time ­available because adolescents were sleeping during this shift. The unit supervisor also completed the A-CRA clinical supervision process, which requires that an individual demonstrate appropriate A-CRA supervision skills during recorded super­vision sessions and the ability to rate session recordings adequately when ratings are compared to an expert rater. Another aspect of this process is for one of the model developers to help shape an internal training process through iterative reviews of training agendas. This was done and a training team was developed, led by the Clinical Supervisor and the first clinician trained and certified in the model. The director of youth services also became a certified expert rater and took on the tasks of maintaining the certification workbooks (electronic spreadsheet for each staff member that shows ratings for each session and progress in certification), and assigning ratings to internal staff trained to do this. There are now regular trainings for new staff in A-CRA procedures.

After the young women’s unit had been using A-CRA for a full year, management staff began discussing the possibility of bringing the model to the young mens’ units. Once again, the decision was made to implement in phases. Primarily due to the volume of recorded sessions that need to be reviewed during the initial certification process, it was decided to train staff on the shorter term male unit first. Also, staff on the long-term unit had the most concerns that the model would be inconsistent with their behavior management approach. In other words, they felt that A-CRA was too “soft” of an approach for the conduct disordered males. The short-term young men’s unit was trained in a ­similar manner to how the young women’s unit was trained, and the clinicians and the clinical supervisor were certified through combining help from the EBT training center and program resources. The young men’s unit has responded very favorably to the model and is experiencing some of the same success that the young women’s unit has experienced. Plans are now in place to spread the implementation to the long-term male unit.  

Recommendations for EBT Imple­mentation in Residential Settings. Fun­ding sources are increasingly requiring treatment programs to use EBTs, and parents are also asking questions about whether programs are using a treatment that has de­mon­strated effectiveness.

As ­resi­dential programs consider implementing EBTs, we suggest the fol­low­ing recommendations:
• Before EBT implementation begins, articulate the goal for implementing the EBT and how success will be measured.
• Anticipate implementation challenges (e.g., staff resistance to change) and how these might be addressed.
• Plan with key staff prior to implementation how an EBT will be integrated with the existing approach and how the existing approach may change. For example, if motivational interviewing was going to be implemented in a program that routinely uses con­frontation and punishment, key staff would discuss how program practices would change to be more congruent with the new approach.
• Educate key staff about the training and competency requirements and ensure there is commitment from the top to fully implement the EBT with fidelity.
• Develop a phased implementation plan to help increase the manage­ability of the implementation process and build on successes.
• Develop multi-level imple­mentation performance indicators and monitor them on a regular basis (e.g., monthly). For example, these can include indicators of clinician progress, supervisor progress and program level progress (e.g., number of competency criteria passed, number of staff achieving competency, whether the supervisor is achieving competency).
• Use creativity in developing a plan to sustain the EBT after initial stages of implementation (e.g., involve shift staff in fidelity assurance work, praise staff for meeting fidelity goals over time).

Dr. Susan H. Godley is a Senior Research Scientist at the Lighthouse Institute of Chestnut Health Systems in Bloomington, IL and directs the Evidence Based Treatment Coordinating Center there. She has been a Principal or Co-principal Investigator on several CSAT, NIAAA, and NIDA adolescent studies.

Mychele Kenney, MS, LCPC is the Director of Youth Services at Chestnut Health Systems in Bloomington, Illinois.
Acknowledgements: This work was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), CSS SAMHSA contract No. 270-07-0191. The opinions herein are solely those of the authors and do not represent the position of the U.S. Government. The authors would like to acknowledge the staff of Chestnut Health Systems’ Odyssey and Discovery Units, with special thanks given to Neal Hubbard and Kelly Luckey. The authors would also like to acknowledge Joan Hartman for her administrative support and commitment, Mark D. Godley for reviewing a draft of this article, and Stephanie Merkle for editorial assistance.  

References
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J. & Funk, R. R. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197–213.
Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. (in press). A large-scale dissemination and implementation model. Clinical Psychology: Science and Practice.
Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. C., Karvinen, T. & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users, Cannabis Youth Treatment Manual Series Vol. 4 (DHHS Publication No. (SMA) 01–3489). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
Jainchill, N. (1997). Therapeutic communities for adolescents: The same and not the same. In G. De Leon (Ed.), Community as method: Therapeutic communities for special populations and special settings (pp. 161–178). Westport, CT: Praeger.
Morral, A. R., Jaycox, L. H., Smith, W., Becker, K. & Ebener, P. (2003). An evaluation of substance abuse treatment services provided to juvenile probationers at Phoenix Academy of Los Angeles. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 213–232). Binghamton, NY: Haworth Press.
Shane, P. A., Cherry, L. G. & Gerstel, T. (2003). Thunder Road adolescent substance abuse treatment program. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 257–284). Binghamton, NY: Haworth Press.
Slesnick, N., Prestopnik, J. L., Meyers, R. J. & Glassman, M. (2007). Treatment outcome for street-living, homeless youth. Addictive Behaviors, 32, 1237–1251.
Springer, D. W. & Rubin, A. (2009). Substance abuse treatment for youth and adults: Clinician’s guide to evidence-based practice. Hoboken, NJ: John Wiley & Sons.
Waldron, H. B. & Turner, C. W. (2008). Evidence-based psychosocial treatments for adolescent substance abuse: A review and meta-analyses. Journal of Clinical Child and Adolescent Psychology, 37, 238–­261.

For most of us, the computer and Internet have become essential tools of our everyday lives and it is hard to imagine working, studying or even planning our days without these valuable and necessary aids. For many young people, spending time on the computer often means playing online video games. Over 90 percent of American young adults do it, and the popularity of online gaming has lately spawned what some behavioral health researchers now point to as video game addiction—a disorder that is most vividly expressed in games known as massively multiplayer online role-playing games (MMORPGs). Despite mounting media coverage that links video games with addictive behavior, mental health professionals cannot fully explain why some online gamers spend ruinous amounts of time in play.

MMORPGs are a rapidly growing genre of Internet-linked computer role-playing games in which a large number of players interact with one another by avatar proxy in a ­complex cyber-fantasy world. In their present form MMORPGs have been around since the early 1990s, and today the most well known of the genre, World of Warcraft®, is played by over 11 million paid subscribers. World of Warcraft® and other MMORPGs are known for a complex and artfully designed online digital environment, capable of supporting thousands of players at a time. These so-called persistent environments are created and maintained by the games’ proprietors, and share the features of a common theme, some form of stage or skill progression, the assumption of a character (the avatar) whose abilities, strengths and role may be customized and en­hanced over time, and often complex social interaction within the game that leads to the development of an in-game culture. Players are encouraged to communicate with each other through text messages and the animated gestures of their avatars, and in fact, must relate to other gamers to play effectively and maintain acceptable progress in achieving individual and communal in-game goals. Players further maximize goal attainment by forming cooperative and interdependent alliances designed to optimize the development of their individual characters and the collective skill set of the alliance.  
MMORPGs appear to be engineered to induce gaming and maximize the amount of time the player stays in play. Game architecture relies on highly reinforcing random reward patterns based on the well-known principles of operant conditioning (Yee, 2006). The time between effort and reward is designed to be very short at first, becoming longer only after the player has progressed to successively higher levels within the game. The reinforcing nature of game structure is significant since children and adolescents often become seriously involved in gaming at an age marked by high neuroplasticity and at a time before their brains have fully developed the ability to manage impulses (MSNBC, 2009).

Data from recent research paint a disturbing picture. One study found that 50 percent of respondents preferred playing a video game over spending time with real-life friends. In the same study, 35 percent of surveyed gamers reported that, compared to real-world interactions, it was easier for them to talk to others over the Internet in the context of game ­sessions. Among video gamers, MMORPG players are more likely to spend what they themselves consider to be excessive time in play than non-MMORPG video game players (Ng, 2005). Gamers in a 2006 study re­ported an average of 22.72 hours per week engaged in MMORPG play, and eight percent of these respondents reported spending in excess of 40 hours per week in play (Yee, 2006). The American Medical Association estimates that more than five million kids may be addicted to online gaming (MSNBC, 2009); and even these figures may understate the problem since, because there are as yet no official diagnostic criteria for video game addiction, most problematic gamers present in a clinical setting for treatment only of comorbid conditions associated with their gaming.  

Sign and symptoms
According to the website Video Game Addiction (2009) psychological symptoms of video game addiction include:  
• Having a sense of well-being or euphoria while at the computer
• Inability to stop the activity
• Craving more and more time at the computer
• Neglect of family and friends
• Feeling empty, depressed or irritable when not on the computer
• Lying to employers and family about activities
• Problems with school or job

Physical symptoms of video game addiction may include:
• Carpal tunnel syndrome
• Dry eyes
• Migraine headaches
• Back aches
• Eating irregularities, such as skipping meals
• Failure to attend to personal hygiene
• Sleep disturbances, changes in sleep pattern

Some ideas now being discussed in regard to the diagnosis of video game addiction might be familiar to clinicians experienced in treating other process addictions—like pathological gambling and spending addiction. As with pathological gambling, video game addiction seems to lie somewhere on the impulsive/compulsive spectrum of disorders. One group that seems to be at particular risk for video game addiction is young men and women who suffer from social anxiety, schizoaffective disorder or autistic spectrum disorders—all conditions in which the affected person tends to experience real-life social interaction as difficult and stressful (Charlton, 2008).  

Social and clinical issues
MMORPG enthusiasts report that they play for a variety of reasons, including: simple entertainment; gaining a sense of community; feeling of achievement; and as a way of ­regulating their emotions (Christie, 2009). Players report enjoying the progression/advancement features of MMORPGs, and find the process of becoming more skilled and better able to master increasingly difficult in-game tasks to be a powerfully rewarding experience (Yee, 2006). Male gamers tend to find greater satisfaction in how their avatars compete with other in-game characters. Males also seem to be more aggressive and domineering in their play, while female gamers appear to place higher value on the quality of in-game relationships and a sense of immersion in the game. These differing styles of play may endorse the findings of neurobiological research that show distinct gender differences in the way test subjects’ dopaminergic circuitry were activated while they were in play (Koepp, et. al, 1998).
Cyber gamers also appear to take the environment of the game very seriously. For some players, relationships in the cyber world become more meaningful and resonant than those of the real world. A cyber environment in which gamers can feel important, competent and powerful may have strong appeal for adolescents whose tentative self-concept and shaky sense of self-worth make real-life social interactions stressful and potentially risky. Adolescent and young adult gamers who have experienced social marginalization in the real world may find great appeal in an escape to a game environment that is dramatic, empowering and one in which other players value them as competent and reliable allies (Yee, 2006).  

Addiction potential
The argument that MMORPG play can be addictive is beginning to gain traction within the behavioral health community. It’s hard to ignore Yee’s (2006) findings that imply both tolerance and withdrawal symptomolgy associated with heavy, long duration video gaming. Fifty percent of re­spond­ents in Yee’s study considered themselves addicted to MMORPG play. In the same study, 15 percent of respondents reported what might be construed as psychological symptoms of withdrawal, feeling angry and irritated when they were unable to play. Thirty percent of those studied also reported that they had continued to play video games even after reaching a point where they had stopped enjoying the experience. Yee also found a significant positive correlation between affirmative responses to questions regarding tolerance and withdrawal and the average weekly time spent in play. As with other process addictions, the addicted gamer seems to become dependent on his or her own neurobiological reaction to being in play.

The neurobiology of video gaming appears to center on dopaminergic systems and activity, in a way similar to pathological gambling. The MMORPG game environment is designed to be filled with challenges that deliver powerfully articulated rewards, and seems to be engineered specifically to get players’ dopaminergic pathways (pathways that mediate interest, focus and reward) activated and resonating. Human beings have evolved physiologically to be drawn to such an environment—even if that environment exists only in cyberspace. In subjects involved in video game play, Koepp and colleagues (1998) found a dramatic increase in dopamine activity (an increase comparable to that observed in a subject intravenously injected with amphetamine) in areas of the brain thought to be involved in reward and learning.  

Treatment and recovery
Effective treatment of MMORPG and other video game addictions should begin with thorough psychiatric and bio-psychosocial assessments designed to identify possible medical, psychological, developmental and social co-factors that may have influence on the addicted person’s gaming activity. Establishing a safe, durable and trusting therapeutic alliance is also an important precursor for helping the online gaming addict appreciate the level of impulsivity of his/her gaming activity and the need for an ongoing and proactive recovery effort. Once the therapeutic alliance has been set, the therapist can help the gaming patient gain a greater awareness of the behavioral, affective, cognitive, situational and temporal triggers to gaming binges. This awareness can be valuable in aiding the patient to develop more adaptive ways to manage triggering thoughts, feelings and behaviors. The gaming patient and therapist should work together to identify difficult feelings the gamer may experience when off-line and particular computer applications, such as chat rooms or other interactive activities that may act as triggers to problematic computer or online gaming (Young, 1999).

In cases where social anxiety is supporting the gaming addiction, the treating clinician may want to focus some time on helping the gamer to develop more adaptive mood intervention and especially anxiety management skills. Some clinicians have encouraged socially anxious video game addicts to engage in face-to-face role-playing card games that can eventually lead to post-game social activities like pizza parties or group outings. In cases like these, mind-body therapies and Cognitive Behavioral Therapy may also be useful (Christie, 2009).  

Gamers, isolated and entrenched in excessive hours of game play may be resistant to the idea of getting help, especially social aspects of treatment like group therapy. Those gamers who suffer from severe anxiety or depression, or who have little social support or willingness to stop ­gaming, may need residential care. This would also be the indicated level of care for gamers who are contemplating suicide.

Recovery from an online gaming addiction is similar to that of substance addictions with one important proviso: Computers have become such a necessary part of our daily lives, that gaming addicts cannot ­reasonably be expected to be totally abstinent from using a computer or going online.  
“It’s like a food addiction,” says Dr. Kimberly Young, clinical director of the Center for On-Line Addiction. “You have to learn to live with food.”  
However, the idea that addicted gamers shouldn’t be expected to eschew all computer use does not mean that they can’t achieve abstinence from online gaming. In the treatment of the online gaming addict, some session time might also be devoted to helping the patient to cultivate the willingness and social skills necessary for a rich and effective engagement in On-Line Gamers Anonymous (OLGA). OLGA is a fellowship based on the familiar 12Steps of Alcoholics Anonymous (AA) where gaming addicts can meet to share their experiences, strength and hope to further their individual and collective recovery from online gaming addiction. Participants often choose a sponsor—another recovering gaming addict with more experience in recovery—who can act as an advisor and confidant, and help the newly recovering gamer work the 12 Steps of OLGA. Sadly, face-to-face meetings of OLGA are currently few, but there are regular online meetings and ongoing OLGA chat rooms. Online interactive OLGA meetings and chat rooms may prove to be something of a double-edged sword, having the dual potential of providing needed social and recovery support but at the risk of triggering, in patients with insufficient recovery stability or affect management skills, destructive computer-related behavior. Some recovering online gaming addicts also attend open AA or All Addictions meetings where they get real-world social support—even if not from other gaming addicts.

Protocols for the treatment of online gaming addiction have not yet been well codified, so clinicians might be well advised to be intuitive, creative and, above all, listen to what patients say works for them. The treatment of MMORPG addiction can be a long process, typically with setbacks along the way. Patience, understanding and persistence are invaluable.

Jeffrey C. Friedman, LISAC  has been a be­havior­al health counselor for over twenty years. He is a primary therapist at Cottonwood Tucson, an inpatient behavioral health treatment center in Tucson, Arizona, where he works with gambling and gaming patients.  He may be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .    

References
Author. (2009). Video game addiction. Wikipedia.org/wiki/Game_addiction.
Author. (2009). Is video-game addiction a mental disorder? MSNBC. http://www.msnbe.msn.com.
Charlton, J. (2008). Video game addicts traits similar to Asperger’s syndrome patients. http://www.thaindian.com.
Christie, M. (2009). Hooked in. Interview on The Age Blogs: Screen Play. http://blogs.theage.com.au.
Koepp, M., Gunn R., Lawrence, A., Cunningham, V., Dagher, A., Jones, T., Brooks, D., Bench, C., and Grasby P. (1998). Evidence for striatal dopamine release during a video game. Nature: 393.
Yee, N. (2006). The psychology of massively multi-user online role-playing games: Motivations, emotional investment, relationships and problematic usage. In R. Schroeder & A Axelsson (Eds.), Avatars at Work and Play: Collaboration and Interaction in Shared Video Environments. London: Springer-Verlag.
Young, K. S. (1999). Internet addiction: Symptoms, evaluation, and treatment. In L. VandeCreek & T. L. Jackson (Eds.) Innovations in Clinical Practice: Vol. 17.

Editor’s Note: This article was adapted from an article that ran in the Journal of Substance Abuse Treatment (JSAT), in accordance with a partnership agreement between Counselor Magazine and JSAT,  to bridge the gap between research and clinical practice in the addiction field.

Cannabis (marijuana) is used by approximately four percent of adults worldwide, with highest prevalence rates in Oceania (including Australia and New Zealand) and North America (UNODC, 2008). In the United States and Australia in particular, trends towards a reduction in cannabis use among adolescents in the eighth to twelfth grade, as indicated in the Monitoring the Future Surveys (Johnston, O’Malley & Schulenberg, 2009; AIHW, 2008); and among 14- to 19-year-olds in the Australian population surveys is laudable, however, these figures still represent a considerable population of young people who use cannabis.

While most cannabis use remains experimental and irregular, the incidence and intensity of use typically increases over the mid- to late-teens (e.g., Coffey et al., 2000), before a decline in use from the mid-20s, which has been associated with the transition to new roles and responsibilities (e.g. Chen & Kandel, 1995).  A minority of young people, however, report use patterns that increase the likelihood of long-term use and dependence, regular use of other drugs and exposure to cannabis-related harms.

A range of studies identify early initiation and regular use in adolescence as significant risk factors for later problematic cannabis (and other drug) use, impaired mental health, delinquency, lower educational achievement, risky sexual behavior and criminal behavior (Copeland & Swift, 2009). 
Few adolescents reporting substance use disorder symptoms receive treatment, although there have been large increases in those presenting for cannabis-related problems in the United States, typically to outpatient settings (Muck, Zempolich, Titus, et al., 2001).  While there is still a developing evidence base, several clinical trials indicate that for this group ­family-based and cognitive behavioral therapies have yielded promising out­comes, particularly when supplemented by contingency management (Stranger, Budney, Kamon & Thostensen, 2009).

To complement these tertiary treatments, there is clearly a need for active secondary prevention efforts to target young people at an early stage of their cannabis use in an effort to minimize problematic use; promote problem recognition; and facilitate informed choice regarding cannabis use and its potential consequences. Several recent studies on the use of brief motivational en­hance­ment treatment (MET) approaches with adolescent substance users have shown promising results (see Monti, Colby and O’Leary, 2001 for a review). One of these approaches is the Cannabis Check-Up, a brief motivational intervention modeled after the Drinkers’ Check-Up for problem drinkers (Miller & Sovereign, 1989). The basic Check-up model comprises a two-session assessment and feedback intervention in which a clinician helps the participant to make in­formed choices regarding their ­substance use. The participant’s substance use is not labeled problematic and there is no confrontation regarding use. A non-judgmental atmosphere is provided, in which questions may be asked and the participant is accepted as the expert on his or her own life. No overt attempts are made to make participants change their use, unless requested by them.

Two recently published feasibility studies, the Teen Marijuana Check-up (Berghuis et al.,2006) and the Adolescent Cannabis Check-up (Martin et al., 2005) employed similar brief (two to three session) motivational enhancement therapies. The studies targeted non-treatment seeking adolescents and focused recruitment efforts on schools and the general community, respectively. Both studies reported significant reductions in the frequency of cannabis use at three month ­follow-up. The absence of control groups, however, precluded drawing causal inferences regarding the impact of the intervention. Nonetheless, it was demonstrated that this type of intervention could attract young cannabis users and was rated positively by them. A subsequent randomized trial (Walker et al., 2006) examined the school-based brief intervention compared with a three-month delayed treatment control group. While, overall, participants significantly reduced their cannabis use during the follow-up period, there were no differences found between the two groups. The authors suggest that the baseline assessment itself (which in­cluded components such as the perceived “pros and cons” of cannabis use), may have prom­p­ted a self-evaluation and acted as a form of brief intervention.
The current study builds on the promising findings of the Adolescent Cannabis Check-up (ACCU) (Martin et al., 2005) feasibility study with a randomized trial of the intervention. We targeted both young people directly, irrespective of their treatment seeking status, and worked with others in the general community to recruit participants for the study.

Current study
The study assessed the efficacy of a brief (two session) motivational and cognitive behavioral intervention for adolescent cannabis users (ACCU) compared with a delayed treatment control (DTC) group in a randomized trial. It was hypothesised that quantity and frequency of cannabis use and symptoms of cannabis dependence would decrease significantly more in the group allocated to immediate intervention.

Selection criteria. The target group were young people aged 14 to 19 years re­cruited from the general community. In order to make the intervention available to a range of young cannabis users, the inclusion and exclusion criteria were broad. Partici­pants were required to be aged 14 to 19 years and to have used cannabis at least once in the past month. Reason­able fluency in English also was required.  Adoles­cents were excluded if they showed evidence of significant cognitive impairment; if they had used more than 80 grams of alcohol per day on average and/or other illicit drugs more than twice weekly in the past 90 days; were current injecting drug users; or they had received treatment for drug or alcohol issues in the past 90 days.

Procedure. The study obtained approval from the Human Research Ethics Committee at the University of New South Wales. A waiver of the requirement for parental consent for participants aged 14 to 18 was obtained to ensure their confidentiality (i.e., young people would not be required to self-disclose their cannabis use to parents in order to participate in the study).

Recruitment efforts targeted both concerned parents and young people directly. Concerned parents were included in recognition of the reality that it is parents (or concerned others), rather than young people themselves, who most commonly seek assistance for an adolescent’s cannabis use (Muck et al., 2001). It was intended to enlist parents to assist in the recruitment of their young person into the study. Concerned parents who contacted study personnel were offered an opportunity (in person or by telephone) to discuss their specific concerns with a project clinician. General cannabis information and a discussion of communication skills were offered. The details of the intervention study also were discussed, with suggestions of strategies the parent might use to encourage the young person to participate. (Details of screening, randomization, procedure and data analysis can be found at Martin & Copeland, 2008).

Participants were followed up by an independent researcher three months after their last involvement with the project. Participants were not paid for their involvement in the earlier sessions but were given a $25 gift certificate upon completion of the three-month follow-up interview.  

The intervention
The content of the intervention was manualized (see brief description below); and the overall style was non-judgmental with an emphasis on engagement and acceptance to promote a spirit of collaboration.
The intervention included rapport-building, and gave the young person discretion and responsibility for decision-making and behavioral change. Sessions were recorded on audio tape and audited by an independent clinician using a structured rating system to assess content delivery, adherence to the intervention protocol and therapist competence.

Session 1: Assessment interview
In the initial session, the clinician collected assessment data on the participant’s substance use, including: quantity and frequency of use; positive and negative consequences of use; the individual’s life goals; readiness for change; and support networks. This information is used to prepare a Personalized Feedback Report (PFR) that is reviewed with the participant in the feedback session conducted approximately one week later.
The assessment interview can be downloaded from http://ncpic.org.au/static/downloads/workforce/­cannabisinfo/assessment-tools/accu-baseline-
assessment.pdf. The measures, such as the Adolescent Cannabis Problem Questionnaire (Martin, Copeland, Gilmour & Swift, 2006) and the time-line follow-back can also be downloaded from this site. The range of psycho-educational materials prepared for the study can be downloaded from http://ncpic.org.au/workforce/alcohol-and-other-drugworkers/cannabis-information/resources/. These include cannabis facts for both parents and young people, as well as tips for talking with a young person about cannabis. 

Session 2: Feedback and skills session
This session was typically held about one week after the assessment session. The clinician provided structured feedback and discussion of information including the individual’s quantity and frequency of cannabis use; money spent; comparison of use with age-specific normative data; the pros and cons of using cannabis; pros and cons of increasing/decreasing use; and perception of interactions between cannabis use and the individual’s longer term goals using a Personalised Feedback Report (PFR).  The PFR can be ordered at http://ncpic.org.au/workforce/alcohol-
and-other-drug-workers/cannabis-information/order-resource. While reviewing the PFR with the participant during the feedback session, the clinician uses MET strategies (e.g., open-ended questions, reflections, reframing, expressing empathy, and avoidance of argumentation) to elicit the participant’s active and candid involvement in the session (Lawendowski, 1998; Miller & Rollnick, 1991). 

The general focus is on encouraging the young person to explore the ­personal meaning and implications of the information in an open and balanced fashion. Ambivalence is accepted as normal and is explored to assist the young person to explicitly consider both the pros and cons of cannabis use and non-use. Where the young person might not acknowledge cons associated with his or her cannabis use, the technique of asking “how would you know when you have a problem?” can be employed. Ex­pressions of motivation for change are reinforced and resistance is minimized by giving attention to motivation both favoring and opposing change. If participants clearly express a desire to change their cannabis use, the clinician supports their self-efficacy by discussing various change options, including self-managed change or referrals to local drug treatment providers. 

Following the provision of feedback a second (optional) component of the session was offered which aimed to provide interested participants with pragmatic strategies for quitting and reducing use. This included a discussion of the nature of cannabis dependence; recognition of personal triggers; managing craving; goal setting; planning for change; behavioral self-monitoring; and relapse prevention. The participant and clinician worked collaboratively through a self-help guide to personalize these strategies for the individual.
The client workbook for this session can be downloaded at http://ncpic.org.au/static/downloads/workforce/training/strategy-workbook.pdf.

Results
Participants. Participants included 40 young people aged 14 to 19 with a mean age of 16.5 years; and were predominately male (67 percent), non-indigenous Australians (88 percent) who lived with their parents (78 percent).  About half (53 percent) were currently at school or studying elsewhere, with a majority (80 percent) either studying or employed. 

Poly-drug use was common. The majority of the sample reported use of alcohol (93 percent) in the past 90 days, with smaller (but still substantial) proportions reporting use of ecstasy (53 percent), amphetamine (45 percent), and cocaine (18 percent) during that period. The mean age of first cannabis use was 12.4 years. The majority of participants (92.5 percent, n=37) reported having used on a daily or near daily basis at some time, with this pattern of use beginning on average at age 14.1 years. 

Participants varied widely in their reported quantity and frequency of cannabis use, with a mean of 65/90 using days and an average consumption of 1,140 cones (water pipes) in the 90-day period. This equates to a mean weekly intake of 88.7 cones. The great majority of the sample (92.5 percent, n=37) met DSM-IV diagnostic criteria for cannabis dependence. The average score on the Severity of Dependence Scale (SDS) was 7.4, indicating some concern among these young people about their own cannabis use. Using a cut-off score of 4 on the SDS to indicate probable cannabis dependence (Martin et al., 2006) this measure also classified the majority (87.5 percent) of young people as dependent. A copy can be downloaded from http://ncpic.org.au/static/downloads/workforce/cannabisinfo/assessment-tools/severity-of-dependence-scale.pdf.

Outcome at three-month follow-up. Of the 40 participants in the study, 32 were successfully followed up at three months, giving an overall ­follow-up rate of 80 percent. Of the intervention group, 90 percent (18/20) completed both sessions of the intervention. The mean length to follow-up was 114 days.

Significant between group differences, in favor of the ACCU group, were found on the change scores of both the days of use and the number of DSM-IV dependence criteria reported. Differential reductions on the mean cones per week measure did not achieve significance, due in part to negative skew and an extreme outlier in the DTC group (see Martin & Copeland, 2008 for detailed findings). With regard to dependence symptoms, there was a substantial change in the proportion of the ACCU group meeting DSM-IV criteria for dependence at follow-up, with a reduction of 35 percent (from 100 percent to 65 percent), as compared with the DTC group’s reduction from 85 percent to 80 percent.
Participant evaluation. The intervention was rated positively by participants. Confidential satisfaction questionnaires were completed by participants in the intervention group following feedback sessions. These confirmed the non-judgmental nature of the intervention and the perceived value of discussing cannabis use issues, receiving feedback, and exploring the pros and cons of using and change. As in the feasibi­lity study, none of the participants endorsed the statement that the feedback meeting was a “waste of time,” and a large majority (80 percent) indicated that they would be interested in further meetings to discuss their cannabis use, if additional meetings were available. In terms of their overall satisfaction with their participation, 90 percent reported they were “very” or “extremely” ­satisfied.

Discussion
The aim of the current study was to examine the efficacy of a brief intervention in reducing cannabis use and cannabis problems among young people who were not necessarily seeking treatment or attempting to moderate their cannabis use. The limited final sample size of 40 participants was determined by time and resource constraints rather than the results of a power analysis based on previous findings. The participants recruited into this study also had considerably higher levels of cannabis use and dependence than those recruited into the feasibility study (Martin et al., 2005).  We did however successfully recruit and retain a sample regular, non-treatment seeking cannabis users, many of whom were dependent.
Participation in the intervention (ACCU) condition was associated with greater reductions in frequency of cannabis use and number of cannabis dependence symptoms reported over the follow-up period. Differential change between groups in the mean quantity of use per week was found but did not achieve significance. The potential clinical significance of the reduction in dependence symptoms reported, however, is evident in the substantially reduced proportion of the ACCU group meeting DSM-IV criteria for dependence at follow-up; reduced from 100 percent of the group at baseline to 65 percent at ­follow-up.

An important finding of the study was that the intervention was valued by the participants. Despite many being coerced (or encouraged) to participate, a large majority of parti­cipants reported they were “very satisfied” with their participation and considered it useful.

This current study has a number of limitations including small sample size in addition to the baseline group differences. The intervention was, however, considered useful by participants and associated with greater reductions in cannabis use than the delayed treatment condition. Given the high levels of dependence in the study population this positive impact is very encouraging. 

The application of the cannabis check-up approach to the population to whom was originally targeted; those young people experiencing problems associated with their use but not yet meeting dependence ­criteria—is a priority.  Further evaluation in a range of settings where young people may have cannabis-related problems, including criminal justice settings, also is required. The intervention could also be easily adapted to more youth-friendly modes of delivery such as web-based interventions and in this way may access this harder to reach and less dependent group.   

Jan Copeland, PhD is a professor at the University of New South Wales in Sydney, Australia and the director of the university’s National Cannabis Prevention and Information Centre.

Greg Martin, PhD is a researcher at the Health Services Research Centre at Victoria University of Wellington in New Zealand.

Acknowledgements: This study was funded by the National Health and Medical Research Council. The authors wish to acknowledge Roger Roffman and James Berghuis (University of Washington, Seattle), and Robert Stephens (Virginia State University) for generously sharing their intervention materials.

References
Australian Institute of Health and Welfare (2008). 2007 National Drug Strategy Household Survey: First results (AIHW Cat. No. PHE 98). AIHW: Canberra.
Berghuis, J., Swift, W., Copeland, J., Roffman, R.A. & Stephens, R.S. (2006).  The Teen Cannabis Check-up.  In: R.A. Roffman, & R.S. Stephens (eds.), Cannabis dependence: Its nature, consequences and treatment (International Research Monographs in the Addictions).  London: Cambridge University Press.
Chen, K. & Kandel, D.B. (1995). The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of Public Health, 85, 41–47.
Coffey, C., Lynskey, M., Wolfe, R. & Patton, G.C. (2000). Initiation and progression in cannabis use in a population-based Australian Longitudinal Study. Addiction, 95, 1679–1690.
Copeland, J. & Swift, W. (2009). Cannabis use disorder: epidemiology and management. Inter­national Review of Psychiatry on Cannabis & Cannabinoids, 21(2), 96–103.
Johnston, L.D., O’Malley, P.M. & Schulenberg, J.E. (2009). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2008 (NIH Publication No. 09–7401). Bethesda, MD: National Institute on Drug Abuse.
Lawendowski, L. A. (1998). A motivational intervention for adolescent smokers. Preventive Medicine 27, A39–A46.
Martin, G. & Copeland, J. (2008) The Adolescent Cannabis Check-up: randomised trial of a brief intervention for young cannabis users.  Journal of Substance Abuse Treatment, 34(4), 407–414.
Martin, G., Copeland, J., Gates, P., & Gilmour, S. (2006). The Severity of Dependence Scale (SDS) in an adolescent population of cannabis users: Reliability, validity and diagnostic cut-off. Drug and Alcohol Dependence, 83(1), 90–93.
Martin, G., Copeland, J., Gilmour, S. & Swift, W.  (2006). The Adolescent Cannabis Problems Questionnaire: psychometric properties.  Addictive Behaviors, 31, 2238–2248.
Martin, G., Copeland, J., & Swift, W.  (2005). Adolescent Cannabis Check-up: feasibility study.  Journal of Substance Abuse Treatment, 29(3), 207–213.
Miller , W. R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior.  New York: The Guilford Press.
Miller, W. R. & Sovereign, R. G. (1989). The check-up: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, &  G. A. Marlatt (Eds.), Addictive Behaviors: Prevention and early intervention (pp. 219–231). Amsterdam: Swets and Zeitlinger.
Monti, P.M., Colby, S.M. & O’Leary, T.A. (Eds.) (2001). Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions. New York: The Guilford Press.
Muck, R., Zempolich, K.A., Titus, J.C., Fishman, M., Godley, M.D. & Schwebel, R. (2001). An overview of the effectiveness of adolescent substance abuse treatment models. Youth and Society 33, 143–168.
Stanger, C., Budney, A.J., Kamon, J.L. & Thostensen, J. (2009). A randomized trial of continency management for adolescent marijuana abuse and dependence.  Drug and Alcohol Dependence, 105 (3), 240-247.
UNODC (2008). 2008 World Drug Report. Vienna: United Nations.
Walker, D.D., Roffman, R.A., Stephens, R.S., Berghuis, J. & Kim, W. (2006). Motivational enhancement therapy for adolescent marijuana users: a preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 628-632.
 

Approximately 90 percent of individuals who develop chronic substance dependence disorders with associated severe mental, psychiatric and behavioral problems start using illicit substances while under the age of 18 (Dennis 2002). However, the largest and most alarming drug problem among adolescents are prescription drugs, particularly prescription opioids diverted from the mainstream medical system, thus further blurring the line between legal and illegal drugs. Prescription drug use among adolescents is a red flag for poly drug abuse, especially if onset is prior to the age of 15 (Brook, Brook, Gordan et al 1990).

Unintentional death involving prescription drugs in adolescence has increased 150 percent between 2001 and 2009. In fact, in 2008 the leading cause of death among adolescents is drug overdose, exceeding even highway fatalities (Cermak 2009). More than one-third of adolescents who began abusing drugs in the last year reported their first drug was a prescription drug. Under the age of 15, non-medical use of a prescription drug is a major indicator of illicit drug use replacing marijuana as the leading “gateway drug” into the illicit drug culture with diversion of prescription opioids, particularly OxyContin, being more available to youth than heroin in illicit drug ­markets.

In a study conducted by John Hopkins, reported deaths from prescription drug overdose rose 273 percent between 2006 and 2008. The spike in deaths can be associated to a dramatic increase in the use of powerful pain killers, such as oxycodone, OxyContin and percocet. Edward Krenzelok, Director of the Pittsburg Poison Control Center, cites that these opioid pain medications are “being tremendously over prescribed and people are not aware of the high risk associated with improper use.” Diversion of prescription opioids from the adult parents involving parent’s medicine cabinets is a major source of drugs for adolescents who abuse prescription medicine (GAO, 2009; Rawson, 2008; Rothman, 2008; Schuckit, 1987; Smith, 2009).

If addictive disease onset is before the age of 15, the severity and duration of disability associated with the addiction is prolonged. However, as described by the National Institute of Drug Abuse (NIDA), the earlier the intervention to disrupt the addiction cycle, the shorter the severity and duration. Earlier interventions and more intensive treatment requiring an inpatient phase with appropriate aftercare in a continuing care model is indicated, as outlined by Timmen Cermak, MD, of the California Society of Addiction Medicine (CSAM) in his “Blue Print for Adolescent Addiction Treatment” (Cermak, 2009) and Rick Rawson, PhD of UCLA Integrated Substance Abuse Programs in his “Continuing Care Model” (Rawson, 2008).

Children who have a family history of alcoholism face a four-times greater risk of alcoholism. Furthermore, some studies suggest that inherited biological traits and psychological characteristics link genetics and substance use with a pattern of poly-drug abuse.
In males the strongest correlation is with attention deficit/hyperactivity disorder as a predictor of early onset addiction, whereas with women, it is depression and eating disorders. Multi-variant analysis, however, makes it difficult to separate genetic factors from the disruptive, dysfunctional and traumatic child rearing environments of the active alcoholic family, irrespective of the socio-economic status of the dysfunctional family (Costello et al, 2002).

Risk factors NIDA outlines the major risk factors for early onset of addiction as:
• genetic predisposition to addiction in first order relatives;
• co-occurring disorders proceeding the onset of addiction;
• childhood psychological trauma; and
• disruptive addictive child rearing environments.

Genetic factors appear to play less of a role in early onset addiction than in adult models, with psychosocial trauma and disruptive child rearing environment playing a bigger role. With adolescent females, sexual abuse in a dysfunctional family environment has shown the strongest correlation with early onset addictive behavior.

In working with high risk traumatized adolescents, a very careful clinical approach is to treat both the trauma and the addiction in an integrative fashion. Traumatized adolescents with addiction disorders often have great difficulties learning recovery skills as their attention is focused on family conflicts aggravated by post-traumatic stress disorder (PTSD) (Guchereau, Jourkiv, Zametkin, 2009).

Treatment
Addiction treatment with female adolescents is less effective unless the psychosocial trauma is dealt with. Covington has outlined a Women’s Integrated Treatment (WIT) model that emphasized gender specific trauma-useful curriculum for the treatment plan (Covington, 2008; Zweben, 2003).      

Guchereau classified that PTSD among adolescents is significantly under diagnosed with a majority of the studies emerging from the juvenile justice system. This has led to the belief that psychosocial trauma and addictive disorder occurs primarily in criminalized adolescents from lower socioeconomic populations which dominate the juvenile justice system. As youth move up the socioeconomic scale, they interface more with the medical system rather than the criminal justice system, and the medical system is much more likely to underreport psychosocial trauma.
This has led to the mistaken belief that there is less psychosocial trauma in middle and upper class adolescents with substance use disorder. In fact, clinical experience has shown that there is a high degree of trauma with early onset addiction, but that it is more hidden and less likely to be criminalized. Upper socioeconomic alcoholic parents with dysfunctional family environments involving physical and sexual abuse retain a veneer of respectability hidden from law enforcement, which often focuses on lower socioeconomic populations (Guchereau, 2009; Merikanges, Rounsaville & Prusoff, 1992).

Studies of the criminal justice system have found that an individual who is poor and non-white is far more likely to be arrested and receive a felony conviction than a white, middle class offender for the same drug offense (Human Rights Watch, 2002; 2009).

Adolescents need a different treatment model for drug addiction than adults, one that focuses on habilitation emphasizing the teaching of psychosocial skills. Adults, on the other hand, require a rehabilitation model that focuses on returning to preexisting recovery skills.
Early onset addiction with co-occurring symptoms requires more clinical skills to deal with trauma in the past because of the denial, shame and guilt that exists in both the patient and the family (Dennis, 2008).

Gender-specific treatment approaches
Clinical experience at Newport Academy has found a very high incidence of psychosocial trauma in young women with early onset addiction. Recent work in the trauma field has focused on traumatized youth to initiate their drug use in order to self-medicate or calm their inner turmoil. This population of adolescents with trauma, that predicted the onset of substance abuse, has a higher incidence of co-occurring disorders, particularly depression and eating disorders in young women.

Studies estimate that one in four adolescents will experience at least one traumatic event in their lifetime before the age of 16. Additionally, there is a high correlation between trauma and the risk for substance abuse later in life. Teens who experience trauma and substance abuse have much higher incidence of academic, psychological and social impairments (Costello, et al, 2002).

To improve clinical outcomes with this population, a gender-specific residential treatment model (as outlined by Newport Academy) provides these adolescents—who otherwise would be very reluctant to disclose such trauma—a safe and nurturing environment to discuss their ­experiences.
Such gender-specific treatment ­models afford adolescents an environment in which to build strong peer support, which is essential in the treatment process. Peer interaction can help facilitate discussions on sensitive issues, such as those of sexuality, assertiveness training, body image issues, the development of strong same-sex role models and the formation of healthy boundaries.

In particular, the specific needs of adolescent girls should be addressed with residential programs identifying and allowing for the differences and needs of adolescent boys and girls.

At Newport Academy, the majority of female residents admitted to the program have experienced trauma—most notably sexual abuse, date rape and sexual coercion. This trauma is not defined by socioeconomic status, and girls in treatment often experience a cluster of symptoms, including: an inability to connect emo­tionally with other residents or staff members; intrusive thoughts and a re-experiencing of the traumatic event; depression; intense distress; body image issues; self mutilation; guilt; shame; and poor self-esteem.

It is critical that any residential environment provide a safe and nurturing setting for adolescent girls to explore these sensitive issues without the obvious distractions that a mixed-gender environment would provide. Research has shown that females in a mixed gender residential program tend to hold back in group settings and have a reluctance to share issues related to sexuality, abuse or rape. Addiction treatment programs can greatly increase their effectiveness through programs that provide gender-specific programming where adolescents are provided a place of healing and where their own experiences can be openly shared and ­valued (Miller, 2003).

Gender-specific adolescent training approaches for adolescent substance abuse and co-occurring disorders at Newport Academy involve creating a safe therapeutic arena where confrontational approaches are not tolerated. The key elements of the clinical program include: appropriate assessment; involving the family throughout the adolescent’s treatment with an Intensive Family Program designed specifically for the identified adolescent and family at week four; developmentally appropriate groups reflecting the differences between males and females; experiential groups to keep teens engaged and to foster a climate of trust; an integrated treatment approach that addresses all the various aspects of the adolescent’s development and needs; and a highly qualified staff trained in substance dependency, co-occurring mental health disorders and adolescent development. In short, effective treatment for adolescents with substance abuse and co-occurring trauma requires interventions that address the unique challenges of both disorders in a gender-specific residential environment.

Dr. David Smith is the Past President of the American Society of Addiction Medicine, Founder of the Haight-Ashbury Free Clinics in San Francisco, Adjunct Professor at the University of California, San Francisco and Chair of Addiction Medicine at Newport Academy.
Barbara Nosal, PhD, MFT is a licensed Marriage and Family Therapist and is the Clinical Director at Newport Academy.
Mickey Troxell, MA, CATC, CEAT II is a nationally recognized Masters Level Equine Therapist and provides Equine-Assisted Psychotherapy at Newport Academy.
Scott Sowle is the Co-Founder and Executive Director of Newport Academy.


References
Blum K., Noble, E.P., Sheridan P.J. et al. (1990). Allelic association of human dopamine D2 receptor gene in alcoholism. Journal of the American Medical Association 263:2055–2060.
Brook, J.S, Brook, D.W., Gordon, A.S. et al. (1990). The psychosocial etiology of adolescent drug use: A family interactional approach. Genetic, Social, and General Psychology 116:111–267.
Cermak T. (2009). “A Blueprint for Adolescent Addiction Treatment,” CSAM Review Council.
Costello, E.J., Erkanli, A., Fairbank, J.A. & Angold, A. (2002). “The prevalence of potentially traumatic events in childhood and adolescence.” Journal of traumatic stress, United States 15(2): 99–112.
Covington, S. (2008). “Women and Addiction: A Trauma-Informed Approach,” Journal of Psychoactive Drugs, SARC Supplement 5. 377–385.
Dennis, M., Barbor, T.F., Roebuck, M.C. & Donaldson, J. (2002). “The Changing the Focus: The Case for Recognizing and Treating Marijuana Use Disorders,” Addiction 97: 514–515.
Dennis, Michael L., Iues, Melissa, White, Michelle K. & Muck, Randolph (2008). “The Strengthening Communities for Youth (SYC) Initiative: A Cluster Analysis of the Services Received, Their Correlates and How They Are Associated With Outcomes.” Journal of Psychoactive Drugs Vol 40 (1) pp 1–16.
Guchereau, M., Jourkiv O., Zametkin, A. (2009). “Mental Disorders Among Adolescents in Juvenile Detention and Correctional Facilities: Post­traumatic Stress Disorder is Overlooked.” Journal of the American Academy of Child and Adolescent Psychiatry, 481–340.
GAO. (2009). Methadone Associated Overdose: Factors Contributing to Increased Deaths and Efforts to Prevent Them. Report GAO 09-341, a report to congressional requesters.
Human Rights Watch. (2002). Punishment and Prejudice: Racial Disparities in the War on Drugs. Report, May 2000. Vol. 12 (2).
Human Rights Watch. (2009). Decades of Disparity: Drug Arrests and Race in the United States. Report, March 2, 2009. 22pp. www.hrw.org/en/
reports/2009/03/02/decades-disparity?
Krenzelok, Edward P., Rita MRVOS. (2009). Profile of medication identification requests managed by a U.S.-certified regional poison information center. Clinical Toxicology, 47, 364–365.
Merikanges, K.R., Rounsaville, B.J., & Prusoff, B.A. (1992). “Familial factors in vulnerability to substance abuse.” Glantz, M. and Picken, R. (eds.) Vulnerability to Abuse. Washington, DC: American Psychological Association, 75–97.
Miller, N. (2003). Consideration of Gender Specific Factors in the Development of Adolescent Alcohol and Other Drug Interventions and Treatment. Gender Differences in Drug Addiction and Treatment: Implications for Social Work Intervention with Substance-Abusing Women. Social Work, 40 (1), 45–54.
Rawson, R.A. (2008). “What is Substance Abuse Treatment and What is It Supposed to Do” CSAM Review Council.
Rothman, B., O’Gorman, P. (2008). Working With Traumtized and Addicted Adolescents. Counselor, 9 (6), 24–29.
Schuckit, M.A. (1987). Biological Vulnerability to Alcoholism. Journal Consulting and Clinical Psychology, 55, 301–309.
Smith, D.E. (2009). “Addictive Disease in Adolescence: A 40-Year Addiction Perspective” Counselor Magazine, 42–45.
Zweben, J. (2003). Special Issues in Treatment: Women. In Principles of Addiction Medicine, 3rd Edition. Chevy Chase MD: ASAM. 569–580.

Addiction professionals across the country are being asked to lead or participate in efforts to shift addiction treatment from an “emergency room” model of acute biopsychosocial stabilization to a model of sustained recovery management (RM) and to nest addiction treatment within larger recovery-oriented systems of care (ROSC). These federal, state and local innovations have focused primarily on the redesign of adult addiction treatment services. This article summarizes a technical report prepared for the City of Philadelphia on potential advantages and limitations of recovery as an organizing concept for services to children (under age 13), adolescents (age 13 to17) and transition age youth (age 18 to 25). The report offers recommendations on how services for these populations can be integrated into recovery- and resiliency-focused behavioral health care systems transformation efforts. The full report (48 pages, 182 research citations) is available at http://www.facesandvoicesof
recovery.org/pdf/White/ChildAdolescents.pdf.

Historical context
Since 2004, the City of Philadelphia has been engaged in a recovery-focused behavioral health care systems transformation process that has mobilized the community to create a recovery vision and align service concepts, practices and contexts (e.g., regulatory policies, funding mechanisms) to support long-term recovery for individuals, families and neighborhoods. Federal, state and local behavioral health ­policy and planning bodies are evaluating the extent to which recovery can be used as an organizing concept for child and adolescent (C & A) services. There is growing interest in creating recovery-oriented systems of care for youth that are family-driven; developmentally appropriate; culturally nuanced; highly individualized; and focused on youth resilience, strengths and empowerment. How­ever, questions remain about the potential advantages and disadvantages of the recovery concept applied to services for children, adolescents and transition age youth.

The average age of onset of AOD use of adolescents entering addiction treatment in the United States is now below age 13. This lowered age of onset of alcohol and other drug use is the most socially and clinically significant American drug trend of the past century.  Lowered age of initial AOD use is linked to greater risk of developing a substance use disorder; accelerated problem development; greater severity of AOD-related consequences; and higher rates of post-treatment relapse. The concept of recovery is more applicable to children, adolescents and transition age youth today than at any previous time in the country’s history.

Child development also can be adversely affected by AOD-related problems of parents or siblings. Children in AOD-affected families are at increased risk for developing such problems as well as experiencing other adverse developmental outcomes. Conversely, the recovery of a parent with AOD-related problems enhances the health and developmental outcomes of his or her children. Adding to such positive effects are specific interventions that en­hance the recovery and resilience of children who have been negatively impacted by parental substance dependence.  

Recovery of adolescents and transition age youth
In 2008, 8 percent of youth aged 12 to 17 and 21 percent of transition age youth in the United States met diagnostic criteria for a substance use (alcohol or illicit drugs) disorder, but less than one in ten of these young people received specialized addiction treatment.  More than 4,900 facilities in the United States currently specialize in the treatment of adolescent substance use disorders, and youth-focused recovery mutual aid meetings in the U.S. have significantly increased in recent years. The importance of these resources is underscored by the consistent research finding that earlier treatment for a substance use disorder (in terms of both age and duration of use) leads to better long-term recovery outcomes. There are evidence-based, brief therapies that have proven effective aids in recovery initiation, but most adolescents are precariously balanced between recovery and relapse in the months following such therapy. Long-term recovery stability is enhanced by sustained post-treatment monitoring and support, stage-appropriate recovery education, assertive linkage to communities of recovery and, if needed, early re-intervention. Unfortunately, such extended care and support is rare. In spite of these limitations, a growing number of young people are using recovery as a conceptual framework to reconstruct their identities and interpersonal relationships following significant and sustained AOD-related problems.

Conceptual frameworks for organizing child and adolescent services
The concepts of “system of care,” “wraparound services,” “positive youth development” and “resilience” have served as organizing frameworks for C & A services in recent decades. Resilience is the achievement of positive developmental outcomes in spite of personal and environmental risk factors. Resilience-based systems of youth development seek to reduce risk factors and increase protective factors at personal, family and environmental levels. Resistance is: an innate hardiness that allows one to be exposed to an infectious agent without becoming ill; and/or  the act of refusing or ceasing AOD use as an act of cultural or political survival (particularly within historically disempowered communities of color). Recovery from a substance use disorder entails three critical ingredients: sobriety, global health (physical, cognitive, emotional, relational, spiritual) and citizenship. These elements of recovery have yet to be fully defined and measured for youth.

Recovery management (RM) is a philosophy of organizing addiction treatment and recovery support ­services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance and the quality of personal/family life in long-term recovery.

Recovery-oriented systems of care (ROSC) encompass the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families affected by AOD problems as well as the creation of values and policies in the
larger cultural and policy environment that are supportive of these recovery processes. Approaches to RM and ROSC for adults and for youth share many elements in common. Efforts are currently underway to identify distinctive changes in services for children, adolescents and transition age youth that need to occur within the movement to RM and ROSC.   

Rather than think of recovery, resilience and resistance in either/or terms, it is helpful to think of systems transformation guided by all of these ­concepts. Many child and family advocates are embracing these concepts as complementary.

Primary Prevention, Early Intervention, Treatment and Recovery Support
Addiction treatment and recovery support services for parents constitute a strategy of prevention for their children. The impact of these services can be further amplified by involving children in the treatment of their parent and by providing specialized services designed to enhance the child’s recovery from the developmental insults of parental addiction and to enhance the child’s future resilience and resistance to AOD-related problems. Some programs (e.g., the Betty Ford Center) have invested considerable resources in the development of services to children affected by parental substance dependence. The treatment of every adult parent should include child-focused prevention and early intervention ­services aimed at breaking the intergenerational transmission of AOD-related problems. RM and ROSC involve an integration of primary prevention, early intervention, treatment and recovery support services aimed collectively at breaking the intergenerational transmission of AOD problems.   

Advocates and critics
Advocates of applying the recovery concept to C & A services extol the concept’s holistic, developmental perspective; emphasis on hope, empowerment and choice; integration of spirituality as a healing/protective force; emphasis on thriving rather than just symptom remission; compatibility with system of care and positive youth development approaches to youth service design; inclusion of such issues as historical trauma and social stigma; and its emphasis on the role of social connectedness in adolescent health. Critics of applying the recovery concept to C & A services contend that recovery is misapplied to children because it: implies returning to a previous level of functioning; brings with it the social stigma attached to addiction; lacks a holistic, developmental perspective because of its “disease” trappings; and works only if integrated with the concept of resilience. Efforts to transform C & A services as part of RM and ROSC initiatives should capitalize on those added ­values recovery brings to the organization of C & A services while seeking to minimize any unforeseen harm that could come from applying this concept to children and adolescents (e.g., risk of over-diagnosis, coerced treatment and financial exploitation of families by the “troubled teen industry”). Embracing and integrating resilience and recovery may be the best means of achieving this added value while minimizing any potential misapplication or exploitation of the concept of recovery.    

The Philadelphia Focus Groups
Members of focus groups (providers, parents and youth) conducted in the City of Philadelphia felt that recovery and resilience were compatible concepts that called for developmentally-informed models of care; family inclusion/direction and leadership; peer support and leadership; a continuum of support; community integration and mobilization of community recovery/resiliency support resources; trauma-informed care (and addressing violence within the trauma framework); and culturally competent care. A particular group of youth much discussed in the Philadelphia focus groups was transition age youth who were “aging out” of the child service system and were no longer eligible for continued C & A services. Hope was expressed that new approaches to such transition planning could be developed given the ROSC emphasis on long-term, stage-appropriate recovery support. Voices from the youth focus groups pleaded for a system of care that would see them as individuals rather than as a disorder and relate to them from a position of respect and authenticity.   

Summary and recommendations
The report ends with a set of recommendations in the following areas:
• concepts and language of systems transformation;
• representation and leadership;
• recovery visibility of youth;
• collaboration and partnership;
• a continuum of (personal/family/community) recovery support;
• practice guidelines; assessment and treatment/recovery planning;
• recovery-focused treatment;
• youth-focused peer recovery culture; and
• evaluation of effects of systems transformation on children and adolescents, their families and on C & A service providers.  

Addiction professionals working with children and adolescents will find much in the report that will help them respond to these issues as they arise within their local communities.

Acknowledgements:  Work on this paper was supported by the Great Lakes Addiction Technology Transfer Center/Center for Substance Abuse Treatment/Substance Abuse and Mental Health Services Administration, the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBH/MRS), and the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (HHSS2832007006I/TO HHSS28300003T Subcontract No: s8440). The opinions expressed are the views of the authors and do not necessarily reflect the official positions of DBH/MRS, CSAT, SAMHSA, DHHS, or the Federal Government.  

William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
Arthur C.Evans, Jr., PhD is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.
Sadé Ali, MA: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.

Ijeoma Achara-Abrahams, PhD: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.
Joan King, APRN, BC: is associated with the Philadelphia Department of Behavioral Health and Mental Retardation Services.


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Recommended Reading
Friesen, B. J. (2005). The concept of recovery:  “Value added” for the children’s mental health field? Focal Point: Research, Policy and Practices in Children’s Mental Health, 19(1), 5-8.
Friesen, B. J. (2007). Recovery and resilience in children’s mental health: Views from the field.  Psychiatric Rehabilitation Journal, 31(1), 38-48.  
Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., & Passetti, L. L. (2007). The effect of Assertive Continuing Care on continuing care linkage, adherence, and abstinence following residential treatment for adolescents with substance use disorders. Addiction, 102, 81–93.
Passetti, L., & White, W. (2008).  Recovery meetings for youth.  Journal of Groups in Addiction and Recovery, 2, 97–121.
Walker, J. S., & Garner, T. (2005). Resilience and recovery: Changing perspectives and policy in Ohio.  Focal Point:  Research, Policy and Practice in Children’s Mental Health, 19(1), 25–26.
White, W. (2006). Recovery across the life cycle.  Alcoholism Treatment Quarterly, 24(1/2), 185-201.  
White, W. (2008). Recovery management and recovery-oriented systems of care:  Scientific rationale and promising practices.  Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services.
White, W., & Godley, S. (2007). Adolescent recovery:  What we need to know. Student Assistance Journal, 19(2), 20–25.