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.

Research is steadily advancing our understanding of substance use disorders, and is spawning ever more effective treatments; however, it often takes several years for therapies with demonstrated efficacy to enter clinical practice (Lamb, Greenlick & McCarty, 1998). As a result, patients are slow to experience the benefits of cutting-edge addiction research. This delay is due largely to the many challenges involved in moving new technologies from the research lab into widespread use.

This process, broadly referred to as “technology transfer,” involves numerous stakeholders, each with unique strengths, resources, needs and expectations that must be coordinated and satisfied for transfer to occur. To accelerate the development and adoption of new addiction treatments, the National Institute on Drug Abuse (NIDA) in 2001, launched the Blending Initiative, a wide-ranging effort that combines and coordinates the knowledge, skills and resources of researchers, treatment providers, policy makers and technology dissemination programs; and in doing so, removes many of the obstacles that commonly impede technology transfer.

Technology transfer
The drive to innovate seems to be an innate feature of human nature; indeed, humans have always created new technologies to reduce labor and discomfort, as well as to be more efficient and productive. Given this propensity, it is surprising that it was nearly the mid-20th century before serious attempts were made to formalize the innovation process and apply it on a large scale. As expected, the strategies used in these initial efforts accorded with that era’s view of technology transfer which assumed that: discoveries made in research laboratories would more or less spontaneously “bubble up” into the hands of potential users; potential users would immediately recognize the intrinsic value of these discoveries; potential users possessed the know-how and resources to use these innovations as intended; and research findings could be disseminated quickly to the broader community of potential users simply by publishing study results in professional journals (i.e. passive dissemination) (T.E. Backer, 2000; T.E. Backer, David, & Souly, 1995). Accordingly, the “diffusion of innovation” has been driven primarily by the publication of research and consensus conference findings in peer-reviewed journals (T.E. Backer, 2000; T.E. Backer et al., 1995).

Since then, however, research and experience have revealed that the transfer of technologies from development to application is anything but spontaneous (Rogers, 2003); indeed, improving the human condition through the purposeful application of technology is an intricate and difficult process which, to succeed, must satisfy several interdependent conditions (ATTC, 2004; T.E. Backer, 2000). Not surprisingly then, traditional technology transfer efforts, independent of the particular knowledge or innovation conveyed, often fail to produce significant and enduring change, even when coupled with user training (ATTC, 2004; Brown & Flynn, 2002).

Unfortunately, the addiction research and treatment enterprise is not immune to these difficulties—several factors can, and often do, slow the adoption of new interventions (Lamb et al., 1998). First, many people inside and outside the world of addiction research and treatment still maintain—despite incontrovertible evidence to the contrary—that addiction is a failing of morality and discipline, rather than a brain disorder. This view tends to undermine the adoption of interventions that address biological rather than moral aspects of addiction. Second, the study and treatment of addiction has not come of age in the context of the medical model in which clinical practice is largely research driven, and the adoption of evidence based therapies is routine. Third, the addiction research and treatment enterprise has relied primarily on ineffective research dissemination strategies (e.g., the publication of study findings in science journals). Fourth, treatment providers often lack the financial, physical and human resources needed to implement a new therapy as it is intended to be, and it may not be clear to what extent a particular therapy can be modified to accommodate available resources and retain a clinically significant effect.

Several workforce issues also are slowing the adoption of new addiction interventions. Foremost among these is the tendency of individuals and organizations to resist change (ATTC, 2004; Diamond, 1995). Such resistance creates a formidable psychological barrier to the adoption of new ideas and practices. For example, a community treatment provider may resist adopting an effective therapy because it contradicts its institutional treatment philosophy and its assumptions regarding the causes and treatment of addiction. Implementing evidence-based addiction interventions will therefore require some individuals and organizations to modify their existing treatment philosophies and behaviors or acquire new ones (T.E. Backer, 1995). Fortunately, individuals’ and organizations’ readiness for change can be enhanced by promoting recognition of technology transfer as change, and including activities in the transfer process that address feelings, attitudes and beliefs regarding change  (T.E. Backer, 1995; Diamond, 1995).

The disciplinary diversity of the addiction treatment workforce also can work against the adoption of new interventions. Addiction treatment is administered by an array of professionals, including: psychiatrists, medical addiction specialists, clinical psychologists, nurses, family therapists and drug and marriage counselors. This diversity is one of the strengths of the U.S. healthcare system, but differences in practitioners’ education, training and experience also make it difficult to address the field broadly and foster systemic change. For example, drug counselors are the front line of substance abuse treatment, and as such, have often been the targets of efforts to incorporate addiction research into practice. Because of differences in education, however, some counselors may be less prepared to make desired changes (Simpson, 2002). Additionally, high
stress and low compensation have produced high rates of job burnout among ­counselors (Simpson, 2002); thus, advances in treatment that do gain a foothold in practice are likely to be lost as the result of worker turnover.

The Blending Initiative
To overcome these obstacles and accelerate the transfer of addiction research into clinical practice, NIDA, in 2001, launched the Blending Initiative. In part, a collaboration with Substance Abuse and Mental Health Services Adminis­tration (SAMHSA)/Center for Substance Abuse and Treatment’s (CSAT) Addic­tion Treatment Transfer Center (ATTC) program, the Blending Initiative is a multi-dimensional effort that “blends” the complementary knowledge, skills and resources of addiction researchers, treatment providers, policymakers and technology dissemination programs into a highly interactive and dynamic collaboration. This collaboration more fully integrates all the various stakeholders into the development and implementation of evidence-based treatment practices.

In its design and development, the Blending Initiative owes much to the work of Everett Rogers. A pioneer in the field of innovation diffusion, Rogers formalized the influential Diffusion of Innovations (DOI) theory, and for more than 40 years, elaborated on the DOI framework, expanding its application to numerous and diverse contexts including health care and substance abuse (Rogers, 2003). The Blending Initiative has been particularly influenced by the following observations and principles defined and organized by Rogers: the diffusion of innovation is a dynamic social process that “flows” through interpersonal networks; the adoption and implementation of innovations is strongly influenced by “opinion leaders” within these networks; end-users participate actively in adopting and implementing innovation; and end-users frequently modify or “re-invent” innovations to better suit their local needs and capabilities. 

The Blending Initiative process begins with the identification of promising research that fills a gap in addiction treatment. These findings are gleaned from trials conducted by NIDA’s Clinical Trials Network (CTN) and other NIDA-sponsored investigations. The CTN, which has 17 regional research and training centers, evaluates the “real-world” effectiveness of drug abuse interventions by conducting clinical trials in diverse community treatment settings with diverse patient populations. The outcomes of these trials are forwarded to a group of researchers and practitioners who participated in the studies; the research is reviewed and its potential for “real-world” application is evaluated. A “blending team” comprised of three NIDA representatives and three ATTC representatives is formed for each research protocol deemed ready for widespread adoption. The ATTC is a network of 14 regional offices and a national office that monitors, translates, and disseminates advances in addiction research. The ATTC also provides treatment professionals with training and assistance to enhance their skills accordingly. These steps in the process are primarily NIDA-driven.

In the next, largely SAMHSA-driven, part of the process, each blending team designs a dissemination plan and develops the materials and activities needed to support adoption of the new practice. Every effort is made to release dissemination products as close as possible to the publication of the relevant research.

Blending teams and dissemination ­products
To date, five separate blending projects have been launched, and the following dissemination/training materials have been developed:
1. Short-term Opioid Withdrawal Using Buprenorphine;
2. Buprenorphine Treatment: Training for Multidisciplinary Addiction Professionals;
3. Treatment Planning M.A.T.R.S.: Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful;
4. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency
(MIA-STEP); and
5. Promoting Awareness of Motivational Incentives (PAMI).

Short-term Opioid Withdrawal Using Buprenorphine. Clonidine has frequently been used to help detoxify opioid-dependent patients (Gowing & Ali, 2006). CTN-sponsored trials conducted in several community treatment programs, however, have shown that more patients following a 13-day tapered buprenorphine detoxification protocol were able to provide an opioid-negative urine sample at the end of the taper, compared to the group receiving clonidine (Ling et al., 2005).

Accordingly, this blending team was charged with creating training materials to inform treatment providers about the detoxification protocol and instruct them in its use. The resulting training package, which is complete and now available, characterizes opiate withdrawal and discusses the rationale for providing detoxification for opioid-dependent individuals; the goals of detoxification; the management of withdrawal symptoms; the risks of overdose following detoxification; and the implementation of the protocol in treatment ­settings.

Buprenorphine Treatment: Training for Multidisciplinary Addiction Pro­fes­sionals. Another buprenorphine blending team was formed and charged with creating materials to increase addiction professionals’ (non-physician) awareness of bupre­norphine treatment. The resulting training package entitled Bupre­norphine Treatment: Training for Multi­disciplinary Addiction Profes­sionals, is available and provides classroom training and self-paced CD-ROM buprenorphine awareness courses as well as research articles and an annotated bibliography. These materials also provide information regarding a variety of relevant legislative, counseling and therapeutic issues.

Treatment Planning M.A.T.R.S.: Utili­zing the Addiction Severity Index (ASI) to Make Required Data Collection Useful. Addiction treatment professionals working in community-based settings often view the Addiction Severity Index (ASI)—a widely administered but under-utilized client assessment tool—as unnecessary paperwork of little clinical value. To promote and facilitate increased clinical use of ASI findings, a blending team was created to develop training materials that demonstrate how ASI information can assist in client evaluation and individualized treatment planning that emphasizes the development of measurable, attainable, time-limited, realistic and specific (M.A.T.R.S.) objectives and interventions. These training materials are now available and include both 6-hour classroom and 4-week online training programs.

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA-STEP). Motivational Interviewing (MI) is a brief behavioral intervention designed to enhance substance abusers’ intrinsic motivation and capacity for change. A CTN-sponsored randomized clinical trial conducted at five CTN-associated community treatment centers evaluated the effect on retention and substance abuse outcomes of the incorporation of MI into a standard intake and evaluation session. This study reported that MI strategies delivered within a single 60-minute session resulted in higher retention rates and a significant increase in the number of sessions completed during the first 28 days of treatment, compared to standard intervention. MI, however, had no significant effects on substance use outcomes at either the 28-day or 84-day follow-up (Carroll et al., 2006). Results of this study suggest that, with proper training and supervision, community treatment providers can effectively implement MI techniques and that integrating MI techniques into only a single initial evaluation session may in­crease retention in the early phases of treatment. Another study reported that six months after meeting with a peer addiction educator during a routine medical care visit, patients who participated in a motivational interview had higher rates of abstinence than patients who received treatment sources list only (Bernstein et al., 2005). Thus, even a brief en­counter with a peer educator utilizing MI strategies can motivate drug ­abstinence.

The Motivational Interviewing Assess­ment: Supervisory Tools for Enhancing Proficiency (MIA-STEP) training materials have been developed and are now available. This product enhances treatment pro­viders’ motivational interviewing skills and the ability of supervisors to provide more structured and focused supervision. These materials—which include a 10-hour supervisor training curriculum, a supervisor tape-rating guide and demonstration materials—provide supervisors with tools to teach, assess and improve counselors’ MI techniques and skills.

Promoting Awareness of Motivational Incentives (PAMI). Contingency management interventions—such as the awarding of prizes, additional clinic privileges and vouchers redeemable for goods and services—aim to modify substance abuse behaviors by ­positively reinforcing objective indicators of drug abstinence (e.g. drug-free urine samples). Several studies have demonstrated that motivational incentives increase patient retention and reduce substance use. Indeed, CTN-sponsored multi-site studies conducted in community-based treatment settings and ­evaluating the efficacy of contingency management interventions as an addition to usual care reported that over 12 weeks, participants receiving abstinence incentives were significantly more likely to submit negative samples than those receiving usual care (at six month follow-up no significant differences were found) (Peirce et al., 2006); and that use of contingency strategies in these treatment settings improved patient retention and drug abstinence (Petry et al., 2005). Despite their efficacy, however, contingency strategies have not been widely adopted in community-based treatment settings.
To address this issue, a Promoting Awareness of Motivational Incentives (PAMI) blending team was formed and charged with creating training materials that increase awareness of motivational incentives and incorporate examples of successful approaches in the use of motivational incentives from the Motiva­tional Incentives for Enhanced Drug Abuse Recovery (MIEDAR) CTN protocol. These materials are now available and include a training video, PowerPoint presentation, brochure, CD of resources, research fact sheet and bibliography.

Additional NIDA blending activities
While the Blending Initiative itself is new, it is consistent with NIDA’s long history of collaborations with agencies outside the NIH. These collaborations range from informal consultations to jointly sponsored research programs such as the NIH/SAMHSA “Science to Services Workgroup” established in 2002. These collaborations are sometimes made more formal by linking funding streams. For example, the linking of NIDA and SAMHSA funding to support implementation of NIDA-funded research protocols in the delivery of SAMHSA-funded services activities. Linking funding streams maximizes each agency’s resources and is allowing NMIDA to ask important services research questions in a cost-effective manner.
The most visible of NIDA’s “blending” activities is the annual Blending Conference. These popular meetings bring researchers and treatment providers together and encourage them to exchange knowledge, experiences and information. The meetings are co-organized with a CTN node and tailored to the specific interests of that region. The meetings include plenary sessions with renowned speakers and workshops led by researchers and providers who discuss the research supporting particular practices, and how these practices have been implemented in particular settings. NIDA also participates in regional and national meetings of State drug abuse agencies with whom it has partnered to enhance the adoption of drug research, and disseminates addiction research and up-to-date drug abuse information via numerous print and Web-based publications that are available on its website.

Over the last 35 years, neuroscientists have made tremendous progress in understanding the biology of the brain. This research has provided incontrovertible evidence that drug addiction is a neurologic disease that arises from drug-induced changes in the structure and function of several inter-related brain circuits. This research also has shown that addiction can be treated effectively with evidence-based therapies. As our understanding of addiction grows, so does our responsibility for ensuring that this knowledge reaches patients as quickly as possible in the form of safe and effective treatments. While moving therapies out of the research laboratory and into the hands of treatment providers involves numerous challenges, NIDA understands that many of these challenges can be overcome by forging a closer working alliance between addiction research and treatment. NIDA’s Blending Initiative accomplishes this by providing the infrastructure and the process needed to integrate research and treatment. As NIDA moves forward in this area, it will continue to work closely with its many collaborators and partners to identify treatment interventions that can be implemented in diverse settings at a reasonable cost by a workforce with moderate training and experience.

Timothy P. Condon, PhD has served as the Deputy Director of NIDA since 1992, where he provides leadership in developing, implementing and managing its research programs and strategic priorities. Prior to that, Dr. Condon served in several senior positions, managing research and service programs at the former Alcohol, Drug Abuse, and Mental Health Administration and directing emerging neuroscience technology assessment for the U.S. Congress, Office of Technology Assessment. He has authored numerous scientific and science policy reports and articles and has received multiple awards for his leadership in setting science policy standards.

Denise Pintello, PhD, MSW is the Special Assistant for the Deputy Director of NIDA at the National Institutes of Health (NIH), overseeing the implementation of innovative initiatives and special projects. In her more than 25 years as a social worker, Dr. Pintello has worked extensively in child welfare, mental health and substance abuse and provided clinical, case management and supervisory services to children and adults. She has also conducted applied research and program evaluations within the fields of child welfare, domestic violence, juvenile justice, mental health and substance abuse.

Lucinda L. Miner, PhD has served as the Deputy Director for Science Policy and Communications at NIDA since 1992, where she coordinates NIDA’s research training and science education programs.Dr. Miner has authored numerous scientific articles and book chapters on the genetic underpinnings of addiction, has served on several Federal Task Forces and Committees, received numerous awards and honors for her leadership in setting science policy standards, including sharing an Emmy award for her contributions to the HBO documentary, Addiction in 2008.

Curtis Balmer, PhD is the senior science writer at JBS International, Inc. He has a PhD in neurobiology and has written widely on substance abuse and addiction.

References
ATTC. (2004). The Change Book: A Blueprint for Technology Transfer (2nd ed.). Kansas City, MO: Addiction Technology Transfer Center (ATTC) National Office University of Missouri-Kansas City.
Backer, T. E. (1995). NIDA Research Monograph 155. Rockville, MD: National Institute on Drug Abuse.
Backer, T. E. (2000). The failure of success: challenges of disseminating effective substance abuse prevention programs. Journal of Community Psychology, 28(3), 363–373.
Backer, T. E., David, S. L., & Souly, G. (1995). NIDA Research Monograph 155. Rockville, MD: National Institute on Drug Abuse.
Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend, 77(1), 49–59.
Brown, B. S., & Flynn, P. M. (2002). The federal role in drug abuse technology transfer: a history and perspective. J Subst Abuse Treat, 22(4), 245–257.
Carroll, K. M., Ball, S. A., Nich, C., Martino, S., Frankforter, T. L., Farentinos, C., et al. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug Alcohol Depend, 81(3), 301–312.
Diamond, M. A. (1995). NIDA Research Monograph 155. Rockville, MD: National Institute on Drug Abuse.
Gowing, L. R., & Ali, R. L. (2006). The place of detoxification in treatment of opioid dependence. Curr Opin Psychiatry, 19(3), 266–270.
Lamb, S., Greenlick, M. R., & McCarty, D. (1998). Bridging the gap between practice and research: forging partnerships with community-based drug and alcohol treatment. Washington, DC: National Academy Press.
Ling, W., Amass, L., Shoptaw, S., Annon, J. J., Hillhouse, M., Babcock, D., et al. (2005). A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction, 100(8), 1090–1100.
Peirce, J. M., Petry, N. M., Stitzer, M. L., Blaine, J., Kellogg, S., Satterfield, F., et al. (2006). Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: a National Drug Abuse Treatment Clinical Trials Network study. Arch Gen Psychiatry, 63(2), 201–208.
Petry, N. M., Peirce, J. M., Stitzer, M. L., Blaine, J., Roll, J. M., Cohen, A., et al. (2005). Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study. Arch Gen Psychiatry, 62(10), 1148–1156.
Rogers, E. M. (2003). Diffusion of Innovation (5th ed.). New York: Free Press.
Simpson, D. D. (2002). A conceptual framework for transferring research to practice. J Subst Abuse Treat, 22(4), 171–182.

This article is published in Counselor, The Magazine for Addiction Professionals, February 2010, v.11, n.1, pp.18-23. 

In the field of alcohol and substance abuse counseling there are many counselors and therapists who are, themselves, recovering addicts or alcoholics. There is a professional and ethical dilemma that occurs when the urge arises for the counselor to disclose that he can relate to his client’s struggle on a personal level , as he too is in recovery. Would doing so shift the focus on to the counselor and away from the client? This dilemma could place the counselor in conflict with personal and professional ethics not to self-disclose. What are the clinical and therapeutic advantages or disadvantages of self-disclosure in the field of alcohol and substance abuse ­counseling?

This article explains the importance of professional and ethical decision making with regard to counselor self-disclosure in the field of substance abuse counseling. There is a process whereby the counselor can make a responsible ethical decision based on criteria that will be the most advantageous to the client. Also, included in this article is an analysis of the implementation of a decision-making process on the specific dilemma, as defined above. Specifically, we will examine the clinical effects of self-disclosure as it relates to alcohol and substance abuse counselors, who are themselves in recovery, treating clients who are addicts and or alcoholics. Is self-disclosure in this scenario a professional and effective therapeutic technique? To tell or not to tell; that is the question that will be answered.

There are several published ethical decision-making formats that could be used to answer most professional and ethical dilemmas. To resolve this question this writer will use a generic format. The first step is to identify the situation that requires consideration and decision making. As mentioned, in the field of alcohol and substance abuse treatment there are many therapists and counselors who are, themselves, recovering addicts and alcoholics. Often, when working with addicts and alcoholics, a counselor will hear this statement from the client—“What do you know about addiction? How can you help me? Everything you have learned is from a book.” If the counselor is in recovery—perhaps for many years and doing well—that would make the client’s statement false. The counselor will know full well and firsthand the insanity of active addiction. The dilemma that requires a clinical decision is: should the counselor  inform the client that his perception of the situation is false and untrue? Would the counselor’s self-disclosure clinically and therapeutically help the client move forward in his treatment? Or, would it be detrimental to the client to share this information with him? Who would be affected by the decision of the counselor to self-disclose?

In the example being analyzed here, both the client and counselor will be affected by this decision in several areas. The level of trust in the relationship could go either up or down. The client will definitely view the counselor differently. Also, the counselor will surely lose some level of professionalism. The resulting shift in differentiation will affect the therapeutic anonymity for both the client and the counselor. If the primary goal of therapy is to aid the client, then the counselor must first establish who the actual client is. A good starting point would be to establish that the counselor is not the client. The client is clearly the client, as identified under the American Psychological Association Diagnostic Statistical Manual of Mental Disorders—IV-TR (2000) for alcohol dependence and or drug dependence. It has now been established that under therapeutic protocol, the client’s needs must come first. The next step is for the counselor to assess his or her relevant areas of competence and of missing knowledge, skills, experience or expertise in regard to the relevant aspects of the situation (Pope & Vasquez, 2007).

In this step, counselors need to be open-minded and able to assess their own areas of competence, whether they are personally in recovery, or not. In this scenario, to be an alcohol and substance abuse counselor, an individual would need specific training, state certification, and in some states, an appropriate university degree in human service for credentialing. With the proper training, education and credentialing, an effective counselor should be able to professionally facilitate and assist the client to advance in his treatment without shifting the focus onto himself and away from the primary objective (i.e. the client’s recovery not his own).   

Training in this specific area of alcohol and substance abuse counseling is available at both the state and national level. The National Institute on Drug Abuse (NIDA) position is that counselors in recovery should use their own judgment, preferably in consultation with a supervisor, about when, how and whether to reveal their own personal recovery experiences. This self-disclosure should be made only with a clear understanding of the potential benefits to the client. At no time should a counselor use the group [or individual] sessions to discuss or resolve his or her own personal problems (NIDA, 2000). In regard to this issue of self-disclosure of recovering counselors in the field of alcohol and substance abuse, there is no relevant legal standard. The decision remains in the hands of clinical directors or as a component of the policies and procedures of the treatment provider. Again, the primary objective is to keep the focus on the client’s recovery.

Since Freud, psychodynamic theorists have generally regarded therapist self-disclosure as detrimental to treatment because it might interfere with the therapeutic process, shifting the focus of therapy away from the client. According to this perspective, the counselor is thought to act as a mirror on which the client’s emotional reactions can be projected. If a counselor discloses personal information during therapy, this therapeutic anonymity could be disrupted. Further, it is argued that counselor self-disclosure may adversely affect treatment outcome by exposing weaknesses or vulnerabilities, thereby undermining client trust (Barrett & Berman, 2001).

It was reported by White (2006) that self-disclosure has become increasingly discouraged in the addictions counselor role. To paraphrase, the use of self—using one’s own personal and cultural experiences to enhance the quality of service—has changed dramatically over the past four decades. In the “paraprofessional” era of addiction counseling in the 1950s to early 1970s, disclosing one’s status as a recovering person and using selected details of one’s personal addiction and recovery history as a teaching intervention were among the most prominent counselor interventions. This dimension of the counselor role was based in great part on the role these dimensions played in successful sponsorship within Alcoholics Anonymous through the 1980s and 1990s. In present day professional alcohol and substance counseling such self-disclosure has come to be seen as unprofessional and a sign of poor boundary management (White, 2006).

The next step in the decision-making process is for a counselor to consider how, if at all, their personal feelings, biases or self-interest might affect their ethical judgment and reasoning (Pope & Vasquez, 2007). Herein may lie the most difficult step in the decision-making process for a counselor who is in recovery and treating a newly recovering addict, either individually or in a group setting. Therapists and counselors are human beings, and as such, have feelings. These feelings might affect clinical judgment and reasoning with regard to setting boundaries, so as to avoid a dual relationship. This is not to say that therapists and counselors cannot be genuine. Genuineness is the ability to be oneself and feel comfortable in the context of a professional relationship with a client. It does not imply a high degree of self-disclosure, but a genuine presence in the therapeutic relationship (OASAS, 2008).  

The primary reason that professional relationships and boundary setting are so difficult for individuals in the fields of psychology, social work and counseling, is that treatment takes place in a healthcare and or mental health setting. In this setting it will be necessary for the therapist to place the needs and care of the client above his or her own needs. This could mean that the counselor may have to listen more than talk. This practice allows the client, through guidance by the counselor, to discover his own solutions. The counselor should not disclose his recovery. In some cases individual counselors like to talk more than listen, and may end up using clients for their own self gratification. Having said that, the field of psychotherapy is not for everyone. Good listeners make good counselors.

If a counselor has even the slightest oncern surrounding the question of elf-disclosure, he should seek consultation from supervision. Is there anyone who would likely provide useful consultation in making the decision to self-disclose? Marsia Booker, LMSW, CASAC (personal interview, Jan. 30, 2009) is the Executive Clinical Director of Interline Outpatient Services, Queens, NY, and was able to be succinct in her consultation for this specific situation being discussed in this article. Ms. Booker explained that when a counselor discloses that he or she is also in recovery from addiction, the client will relate to this shared experience rather than the professional ability of the counselor to treat them. Ms. Booker went on to explain that the client will start to relate to his counselor as a peer. In this process, the counselor loses his or her professional status and lessens his or her ability to effectively treat the client. There is a loss of differentiation that can damage the therapeutic relationship. Therefore, Ms. Booker’s clinical position is that her counselors and social workers, who are also in recovery, not self-disclose to their clients who are in treatment at Interline Outpatient Services.

One might ask at this point–what could be an alternative? The answer to this question is a challenging one. The alternative course of action is for the counselors not to broadcast that they are also in recovery. When a counselor hears a statement from the client like: “What do you know about addiction? How can you help me? Everything you have learned is from a book.” A client my simply ask; “Are you in recovery, too?” The counselor must invoke an alternative response other than self disclosure. A possible alternative could be: “This is not about me—it is about you. How can I help you to develop a recovery plan that works for you?” This strategy will get the focus back on the client. Or possibly: “How I got here is not important. What is important is how you got here and how I can help you move forward in your personal recovery.” What is most important is how the client came to be in that seat not how the counselor came to be in his or her seat. Again, this strategy will turn the focus back onto the client and make his or her recovery the primary objective of treatment.

As an additional decision-making strategy, try to adopt the perspective of your clients. From the client’s perspective this writer would rather have his counselor in the role of a highly trained and highly educated professional. The client needs to see his counselor as a professional individual who has the knowledge and ability to help him recover. As the client, this writer would not wish to relate to his counselor as a peer and thereby damage the therapeutic relationship. Upon careful review of this decision-making process, this writer would be very comfortable with making the decision not to self-disclose.

Counselor self-disclosure exists and will continue to exist in the field of psychology and counseling. Bridges (2001) points out that while most counselors engage in some form of disclosure, intentional decisions to share feelings and personal views with patients remain a complex area of clinical practice. This article can report that not all self disclosure is inappropriate. There are  times when self-disclosure works, if it relates to information that the client may be stalled in understanding, or it relates to what is taking place right in that moment. For example, if a client is revealing parenting issues, a counselor may admit that he or she is also a parent, and offer professional therapeutic insight as a counselor/parent. This is not to be confused with the argument that counselor self-disclosure aids in client self-disclosure. Barrett and Berman (2001) state that “although our evidence indicates that therapist self-disclosure can be helpful for treatment, it does not confirm the argument that therapist self-disclosure exerts its impact by encouraging client self-disclosure.” Self- disclosure is not an effective technique for aiding the client in being more open and forthcoming.

Clinicians repeatedly encounter dilemmas for which a clear professional clinical response can be elusive. Standards and procedures cannot take the place of an active, deliberative and creative approach to fulfilling clinical responsibilities. Being prepared in advance and having a decision-making process in place is important because in the human services and healthcare industry, these situations may arise without warning and may need to be addressed fairly quickly. Therefore, know in advance that you are going to be challenged by your clients in regard to this question. It may come as a form of deflection whereby the client is deflecting the attention away from himself. Do not be fooled!  Be prepared in advance with your answer, as suggested above, and return the focus where it belongs; back onto the client.

Continuing training and counselor wellness are key components to the operation of an effective treatment program. Counselor wellness and client wellness are intrinsically and proportionally related.  It is the recommendation of this writer that clinical supervisors provide adequate and ongoing training to counselors and social workers who are themselves in recovery and working with newly recovering addicts in treatment, particularly adolescents. Thera­pists and counselors may self-disclose in other areas, when therapeutically advantageous for the client. However, the disadvantages, as analyzed herein—even the perceived disadvantages to the homeostasis of the therapeutic relationship—far outweigh any possible advantage that self-disclosure might offer. Therapists and counselors who are also recovering addicts and alcoholics and who wish to be considered professional and effective should not, under any circumstances, self-disclose to his or her clients that they are also in recovery. The new question you now need to ask yourself is—are you up to the challenge?

William A. Rule, MS/Psy, CASAC holds a degree in psychology and is a certified substance abuse counselor for the state of New York. He has more than 20 years experience in the field of recovery from addiction, has authored the No Matter What! Relapse Prevention Workshop © which is available free online at www.imustnotuse.com, and is a co-founder and VP of Development for the first nationwide satellite television show based on addiction recovery. He also serves as coordinator of the special needs (MICA) program at an outpatient clinic, and does volunteer educational and prevention work within his community in Long Island.

References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author
Bridges, N. A. (2001). Therapist’s self-disclosure: Expanding the comfort zone. Psychotherapy 38;1.  January 23, 2009 from: http://search.ebscohost.com.ezproxy.apollolibrary.com
Barrett, M. S., & Berman J. S., (2001). Is psychotherapy more effective when therapists disclose information about themselves? Journal of Counseling and Clinical Psychology. Retrieved January 23, 2009 from: http://search.ebscohost.com.ezproxy.apollolibrary.com
Pope, K.S., & Vasquez, M.J.T. (2007). Ethics in psychotherapy and counseling. San Francisco, CA: Josey Bass. Retrieved January 12, 2009 from: https://ecampus.phoenix.edu
Office of Alcoholism and Substance Abuse Services, NYS (2008). Motivational interviewing in a chemical dependency treatment setting. Retrieved January 23, 2009 from: http://www.oasas.state.ny.us/AdMed/documents/motinter06.pdf
White, W. L., (2006). Sponsor, recovery coach, addiction counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health and Mental Retardation. Retrieved January 23, 2009 from: http://www.oasas.state.ny.us/recovery/documents/WhiteSponsorEssay06.pdf

This generation of leaders in addiction treatment is passing. Long-tenured pioneers in the field have retired or will soon retire. For those about to pass the torch of leadership, it is a time to reflect, teach and mentor. For those into whose hands this torch will be passed, it is a time for preparation. To acknowledge this generational transition, the author is conducting interviews with some of the modern champions of addiction treatment in the United States. This effort will honor these individuals and acknowledge that their work has made a great difference in the lives of individuals, families, and communities throughout the United States. This series also will give a new generation of addiction professionals and aspiring leaders an opportunity to learn from those who created the field that they now inherit.

The modern field of addiction treatment came alive as a national system of care in the early 1970s through a unique federal/state/local community partnership that continues to evolve today. The first interview in this series is with an individual who was at the center of this birthing and who has continued to serve in this field for four decades. He has been a valued colleague and friend to many. His insatiable passion for addiction recovery is greatly admired by this author.  Wherever issues criti­cal to the future of addiction treatment and recovery are discussed, you will hear his voice. Join me below in exploring the life, times and ideas of Dr. Robert DuPont.   

Robert L. DuPont, MD served as White House Drug Czar for Presidents Nixon and Ford and was the founding Director of the National Institute on Drug Abuse (NIDA). He is the author of The Selfish Brain: Learning from Addiction. Dr. DuPont is the founding President of the nonprofit Institute for Behavior and Health, Inc, an organization devoted to finding and promoting new ideas to reduce the use of illegal drugs (www.ibhinc.org).

Entering the field
Bill White: Describe how you chose to devote your life to the addictions field or perhaps how this most unusual profession chose you?   

Dr. DuPont: When I left the Harvard Medical School and the National Institutes of Health (NIH) on June 30, 1968, to take my first job as a psychiatric physician, I wanted to use my education and whatever skill I could muster to help the men and women in prison. I had worked during my residency in the historic Norfolk Prison in Massachusetts, the prison in which Detroit Red served six years for burglary before coming out as Malcolm X. Hooked for life on prisoners and their stories, I was inspired by John F. Kennedy and Martin Luther King, Jr. to devote myself to the cause of prisoners. I wanted to help prisoners and their families, and I also wanted to help communities that were at that time suffering from a major crime epidemic.

I joined the District of Columbia Department of Corrections full-time on July 1, 1968. In less than a year, I became head of community corrections and parole for Washington, DC. In August 1969, with a handful of college students on summer vacation, we tested the urines of every man entering DC Jail. We found that 44 percent were positive for heroin. Further­more, we found that the year they first used heroin demonstrated the onset of the heroin epidemic that was fueling the crime wave that led to Washington being labeled “The Crime Capital of the Nation.” These results were published in the prestigious New England Journal of Medicine.

In response to the findings of this study, I started a crash course to learn about addiction treatment under the guidance of Vincent Dole, Marie Nyswander and Jerry Jaffe. On Sept. 15, 1969, I started the first methadone treatment program in Washington with 25 prisoners on parole. On Feb. 18, 1970, Mayor Walter E. Washington appointed me head of a new city-wide heroin ­addiction treatment program, the Narcotics Treatment Administration (NTA). Within two months, we had 2,000 addicts in treatment in 12 treatment centers.

On April 1, 1970, Chief Judge of the DC Superior Court, Harold Green, announced the first universal drug testing program in the country. All criminal defendants were given drug tests by NTA, with this drug testing function later being absorbed by the court itself. This assertive approach of intervention became the model for the White House-sponsored TASC (then meaning Treat­ment Alternatives to Street Crime), the forerunner of most criminal justice programs linked to treatment, including drug courts. This criminal justice system initiative fulfilled my vision of helping criminals reclaim their lives and helping their communities heal from the ravages of the crimes they committed. Addiction treatment was the key to achieving these objectives. 

These initiatives helped generate a 50 percent drop in FBI Index crimes in the nation’s capital between 1970 and 1973, and brought 15,000 heroin addicts into treatment at NTA. We demonstrated that successful heroin addiction treatment helped addicts and, when delivered on a massive scale, also helped the entire community. These results were documented in more than 200 professional publications in those three years and sparked the biggest change in federal drug policy in the second half of the 20th century. That shift created a balanced approach of traditional law enforcement (the supply side) with a parallel and roughly equally-funded effort in treatment, prevention, and research (the demand side). At the age of 37, I became the White House Drug Czar and first head of the  NIDA. I was hooked for life on the prevention and treatment of addiction; I had found my life’s work.  

Bill White: What did you learn during this period from Dr. Vincent Dole and Dr. Marie Nyswander and from your own experience about the potential and limitations of medications in the treatment of drug addiction?

Dr. DuPont: Dole and Nyswander were two of the most impressive people I ever met. Dole was the biological scientist and the relentless entrepreneur. Nyswander, the soul of their operation, devoted her life as a psychiatrist to helping addicts. Together they moved mountains by the force of their science, their determination, and their engaging personalities. They were the “irresistible force” that made possible my work and the work of countless others. Even the drug-free community, often at odds from the outset with Dole and Nyswander, has enormously benefited from the major public and private investments in addiction treatment that flowed directly from the work of this dynamic physician duo. Dole and Nyswander played a central role in getting official Washington to support NTA. Later, I learned that Vincent Dole served several years as a non-alcoholic trustee of Alcoholics Anonymous (AA).

Most of NTA’s patients used methadone as one part of their treatment, but NTA also had a large residential detoxification program that was not related to long-term methadone and a variety of outpatient drug-free programs including frequent visits to a counselor and a sophisticated therapeutic community. NTA contracted with many other treatment programs in the community, most of which were drug-free, to provide treatment reimbursed through contracts with NTA. NTA encouraged patients to choose the treatment they wanted and that best fit their needs. 

Bill White: At a national policy level at this time, there seems to have been more of a focus on what methadone could subtract by way of crime at a community level than what methadone could add by way of personal recovery and quality of life for individuals and families. Is this an accurate perception on my part?

Dr. DuPont: I got into drug treatment in 1968 to fulfill my initial goal of helping criminals, so I considered reducing crime to be a major public health objective. It is also a major public safety objective. Think of it like reducing drunk driving. That too is a major public health and a major public safety objective. I have never understood the logic that says that reducing crime is not humane and generally valuable, most especially to criminals whose criminal lifestyles not only put the general public at grave risk but also put their own lives and futures at significant risk.  

In the late 1960s and early 1970s, crime reduction was one of the three measurable goals of drug abuse treatment. The other two were reducing drug use and increasing employment. The original methadone program in New York was studied by Francis Gearing, MD, from the Columbia University Medical School. This independent evaluation was the evidence that methadone treatment worked. No other drug treatment program at the time (and very few since) has had that level of independent evaluation. Gearing’s findings were clear: achieving those three goals went together. When you reduced crime in a group of addicts, you reduced drug use and you increased employment. We never used the word “recovery” in those days, but achieving those three goals constituted a foundation of personal recovery. 

Over the past few decades, crime reduction occasionally has been politicized as a “conservative” goal while “addiction treatment” has been defined in contrast as a “liberal” objective. As a lifelong Democrat who worked proudly in the White House of two Republican Presidents (Nixon and Ford), this way of thinking about drug policy made no sense. The conservatives I know support addiction treatment, and the liberals I know support crime reduction. How could it be otherwise? Anyone able to think clearly about addiction and crime must see that crime and illegal drug use are closely connected and serious human problems that justify major efforts aimed at reducing both of them.  

What is too often overlooked is that it took more than medication to achieve those successes at NTA. Medication worked best when it was part of a broader process of psychosocial rehabilitation led by the NTA counselors. That is still the case today.   

Bill White: What did you learn in your early leadership of NTA about the role of counselors in the treatment of addiction? 

Dr. DuPont: We had a lot of counselors, generally one for every 25 patients, including those in our methadone program. At the time, I thought the more counseling, the better. Only in later years did I ask the question about what the counselors were doing with those addict patients when they met with them. I know the NTA counselors took an interest in their patients and encouraged them to stop drug use, to be compliant with the NTA program, and to not commit crimes. Most NTA counselors were not former addicts and few of them had any formal education in psycho­therapy—virtually none were social workers or psychologists. Today, addiction counseling has been professionalized with the introduction of cognitive-behavioral therapy and a variety of well-developed strategies to promote recovery. None of that existed in the early 1970s.   

Bill White: One of the things about your leadership at NTA was the emphasis you placed on mobilizing the whole community within the treatment and recovery process. 

Dr. DuPont: NTA could not have been more visible to the Washington, DC, community. We had an independent advisory committee appointed by the Mayor to oversee everything we did. NTA was in the news regularly. I testified before Congress dozens of times each year. NTA had so many visitors from all over the country that we had to have a full-time staff to handle the visits of as many as 20 or 30 people a day. One of our most distinguished visitors was the first term Governor of Georgia, Jimmy Carter, who was so impressed, he flew back to Georgia to set up a statewide program modeled on NTA.

All this attention was not favorable. NTA, and especially our use of methadone, was controversial from the start, leading the local CBS television station to conduct a one-hour prime-time investigative report that was highly critical, focused especially on methadone. The firestorm was quickly extinguished when both Washington newspapers, the morning Washington Post and the Evening Star, editorialized in support of NTA and methadone as part of a comprehensive treatment program. It is critical that the larger community under­stands addiction recovery and that each community institution contributes in its own way to support long-term recovery.  

The NIDA years
Bill White: How did you come to serve as the first director of NIDA?

Dr. DuPont: I was appointed to succeed Jerry Jaffe as Nixon’s second White House Drug Czar as Director of the Special Action Office for Drug Abuse Prevention (SAODAP) on June 17, 1973, with the understanding that the office was set to terminate on June 30, 1975. Most of the demand-side activities of the federal government were to be carried on by NIDA, which was authorized by the same law that established SAODAP. I started NIDA as Director in September of 1973. Casper Weinberger, the Secretary of Health, Education and Welfare (HEW), chose me to head NIDA. As if heading two major offices at the same time was not challenge enough, I was also temporarily assigned in 1975 to serve as the acting head of the Alcohol, Drug Abuse and Mental Health Admini­stration (ADAMHA), the agency to which NIDA then reported in the vast HEW bureaucracy.

I could say that I was chosen because I had done an outstanding job running NTA and played a leading role in drug policy at the time. A simpler answer is that I was chosen to lead NIDA because I was well-known to the White House and the Congress in 1973. I was under their noses in Washington and very visible. That made me easily accessible, familiar, and for many of the leaders in the White House and Congress, a “safe” choice to become NIDA’s first ­director.

Today, NIDA, part of NIH, is devoted to research on drugs of abuse. When NIDA began—and until the creation of the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1992—it contained the full range of the federal government’s demand reduction programs including not only research but also treatment, prevention and training.

Bill White: You were present at the birthing of modern addiction treatment in the early 1970s. How would you compare the collective vision of the pioneers from that era with today’s system of addiction treatment?  

Dr. DuPont: In the late 1960s, there were few experts in addiction anywhere except those working at the Addiction Research Center in Lexington, KY, which had been founded in 1935 as the “Narcotics Farm” to provide treatment and conduct research focused on heroin addiction. When the modern drug abuse epidemic swept the nation, there followed an intense search for leaders who could respond to this epidemic. A group of ambitious young physicians, mostly but not all psychiatrists, stepped forward to fill this leadership vacuum, including Ed Senay, Bob Newman, Jerry Jaffe, Herb Kleber, Lee Dogoloff and Peter Bourne. This group, which never numbered more than about 20, established modern drug treatment programs in a spirit of inspired competition. Four of these people were the first four White House Drug Czars: Jaffe, me, Bourne and Dogoloff. NIDA assumed leadership at the Federal level, and the modern drug treatment system, including the leading role for the states, was established.

Never before or since have I been part of such a remarkable outpouring of creativity. It was a unique moment in history for everyone involved. Since that time, addiction treatment has become far more of a standardized commodity. The number of physicians in leadership roles has ­diminished. Innovation continues in addiction treatment and is probably even greater today than in those early years, but it is more dispersed and much less visible than in the early 1970s when addiction treatment was new and often front-page news.

I single out the uniquely important role of Jerome H. Jaffe, MD—the first White House Drug Czar. Among his many contributions, Jerry invented the modern “multimodality” treatment program. This brilliant strategy solved the intractable conflicts between the methadone advocates and the drug-free advocates by combining them into a single program that offered many choices to patients.

At that time, I overlooked the 12-step fellowships (truly the ignored elephant in the living room of drug treatment) and the unity of addiction (as opposed to a substance-specific view of the disease). When I was at NTA, I established an informal ex-addict advisory group of 10 clean addicts who worked for NTA as counselors or in other roles. They were inspiring and contributed greatly to NTA’s success. Years later, I encountered one of these ex-addict advisors and asked him about the other group members. “All dead” was his report. I was puzzled when he told me that most had died, not of heroin addiction, but of alcoholism. I asked, “Why are you alive and they are dead?” His response shaped my thinking forever after, “I went to AA and Narcotics Anonymous (NA) meetings, and they didn’t.” In those years, I entirely missed the importance of the 12-step programs and the unity of addiction.      

Today, I see these fellowships as a modern miracle and the key to sustained recovery for most, but not all, addicts to alcohol and other drugs. In fact, these programs created the entirely new concept of “recovery,” which is much more than mere abstinence. The 12-step fellowships support a new and better way of life. They are about character as much as about abstinence. In these fellowships, people find what is needed to achieve not only sobriety but recovery. I tell my skeptical addicted patients that help, support, guidance—love—is there for them when they are ready to accept it. I see my job as conveying those two messages to every person with alcohol and other drug problems with whom I have the privilege to work, as well as to their families, whom I refer to Al-Anon. My patients, over the course of many years, taught me that these programs are one of the greatest gifts of America to the global culture. 

In addition to missing the value of recovery fellowships, I also missed the most important development in the field, the emergence of the Minnesota Model of addiction treatment. This model combined professional treatment with physicians, psychologists, social workers and counselors in recovery in a 28-day residential treatment design aimed at facilitating lifelong participation in AA and NA. Family involve­ment was central to this model (and virtually absent from NTA and many other drug treatments then and now). The Minnesota Model, growing out of the 12-step fellowships, never fell for the substance-specific view of addiction and treatment that all pharmacotherapies reflect. The Minnesota Model from its beginning to this day has had a unitary view of addiction, defining sobriety as freedom from any use of alcohol or unprescribed psychoactive drugs. That revolutionary idea remains unfamiliar to many in our field, even into the 21st century!

Bill White: What other milestones of modern addiction treatment are noteworthy?

Dr. DuPont: Managed care came into the addiction treatment picture in the 1980s to reduce costs. Managed care stopped the growth of residential treatment and spawned the widespread use of Intensive Outpatient treatment. It also reduced the duration of treatment with its obsessive focus on costs. Such shortened length of treatment is at odds with the new view of addiction as a lifelong disease. 

Some of the major drivers of innovation in treatment today are in the private sector where the 28-day program has evolved into not just longer stays (90 days becoming commonplace) but into extended care options such as Oxford Houses, and in care management where the Physician Health Programs (PHPs) are setting the standards. The recovery coach model is also extending services from brief intervention to lifelong recovery management. The new care management movement focuses on maximizing long-term recovery outcomes rather than on reducing costs the way managed care does.

There are several promising new models of care management in the criminal justice area, most of which use prolonged, intensive monitoring linked to swift, certain, but generally not severe, consequences. They strengthen one of addiction treatment’s weakest links—early termination and a revolving door that has failed to meet the needs of many patients and that has proved to be a tragic waste of limited public resources.  

Bill White: One of the many notable things you did at NIDA was set up a national training system for the physicians, nurses and addiction counselors working in the rapidly expanding network of community-based treatment programs. How important was that early training system to the professionalization of addiction counseling and the evolution of modern addiction treatment? 

Dr. DuPont: The Career Teachers Program, which NIDA shared with the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which was established two years before NIDA, was one of the most important steps taken in NIDA’s early years. That program created a body of academic expertise in addiction medicine and set in motion the develop­ments that would culminate in the establishment of the American Board of Addiction Medicine (ABAM) in 2009. I am proud to be among the first physicians to achieve this new board certification. At NIDA, the Career Teacher program was led by Jim Callahan, who went on to become the remarkably effective executive director of the American Society of Addiction Medicine (ASAM) and who currently serves as the Executive Vice President of the American Board of Addiction Medicine. ASAM has become the home of the new medical specialty of addiction medicine, extending far into the future the work started with the Career Teacher Program. The Career Teacher Program was part of NIDA’s national training system that included national, regional, and state training programs for addiction counselors under the overall direction of individuals such as Dr. Lonnie Mitchell and George Ziener. Many of the nation’s early generation of addiction counselors were mentored within NIDA’s training system.

From treatment to recovery
Bill White: You seem to have shifted over the course of your career from an emphasis on addiction treatment as the vehicle of recovery initiation to the view that treatment is only a milestone in a much larger and more enduring process of addiction recovery. Have I accurately read that shift in emphasis?

Dr. DuPont: You have me nailed. I used to think of drug abuse treatment as something like the “treatment” of cigarette dependence today. It is hard; many people fail to stop smoking cigarettes. Mostly, it takes determination and often some help, including pharmacological help, but once done it is, for most people, done. There is a lot of relapse in smoking cessation, but most relapses are early. There are not many people in long-term programs for smoking cessation although there are 50 million former smokers in the country.

Methadone treatment, as defined by Dole and Nyswander, was for life. They made the analogy of methadone and heroin addiction to insulin and diabetes. Diabetics cannot live without insulin, and heroin addicts, in their view, could not live without methadone. Modern methadone treatment did not work that way. Only a small percentage of patients stayed for a long time, let alone for a lifetime. In the early 1970s, I viewed addiction treatment as an important but limited episode in the lives of drug addicts. In stark contrast to my earlier views, I now see addiction treatment as a brief, but often life-saving learning opportunity for addicted patients. Good addiction treatment provides an introduction to lifelong participation in the 12-step fellowships and other forms of long-term recovery support. This view recognizes the lifelong nature of addiction, the lifelong support commonly needed to prevent relapses, and the important role of addiction treatment in supporting lifelong recovery. 

Drug courts and drug testing
Bill White: You have been a real champion of drug courts. What is distinctive about this model of intervention?

Dr. DuPont: To be unmistakably clear, the most important innovation in addiction treatment in the past two decades is the drug court. Janet Reno, who started the drug court movement in Miami in 1988, rode the wave to the Cabinet, becoming a revered Attorney General. Re­mem­ber that I came to addiction treatment from corrections. It was obvious from the start of my career that the criminal justice system had great potential for helping offenders, most of whom suffered from addiction to alcohol and other drugs. The term today is “therapeutic jurisprudence,” meaning using the strong arm of the law constructively and humanely to achieve public health goals.

Today, many people mistakenly believe that the big choice in drug policy is “prison” or “treatment,” pitting the supply side of the drug policy strategy against the demand side as an either-or choice. No drug policy formulation is more destructive than that! Start with the reality that nearly half of all people in treatment for addiction are there because they were sent to treatment by the criminal justice system. Today, the major challenge of drug policy is to find better ways to link the criminal justice system and addiction treatment so that together they can achieve results that neither system can achieve alone. The important choice for the future of drug policy is not “the criminal justice system” or “addiction treatment”—it is “the criminal justice system” and “addiction treatment.” That improved linkage is the unique—and immensely valuable—contribution of the drug courts.

The drug policy opportunities for this linkage are bigger even than drug courts, which reach a small percentage of the more than five million Americans in their communities under criminal justice supervision, mostly probation and parole. To help more addicts and to improve public safety, our country needs to use the leverage of the criminal justice system to enforce strict no-use standards for illegal drugs and alcohol as a condition for criminal offenders remaining in the community. HOPE probation, an innovative program in Honolulu, has shown a way to do this so as to reach everyone on probation. By using frequent random drug and alcohol tests linked to swift, certain, but not severe, punishments (a few days in jail), this new program shows, as do drug courts, that this strategy reduces revocations, incarcerations, and new crimes in this high risk, drug abusing population.

Bill White: You have been a strong advocate of the use of drug testing as a clinical tool in addiction treatment. Do you feel this tool is still being underutilized by addiction professionals?

Dr. DuPont: Drug testing is used far too little in addiction treatment and drug testing is often poorly used. Too many people working in addiction treatment today are caught in the view of substance abuse, that relapse is part of the disease, and therefore, relapse to alcohol and other drug use is to be accepted and tolerated patiently until and unless the drug abuser decides to give up drug use. “Reduced use” is substituted for “Abstinence,” as the goal of addiction treatment. Com­pounding this problem, the goal of treatment is often defined as substance specific. If a patient has a heroin problem—cutting down on heroin use is seen as a legitimate treatment goal while continuing use of alcohol, marijuana, cocaine and other drugs while in treatment is seen as secondary if not trivial. In this view, abstinence is seen as a far distant goal of treatment.
To me, any use of addicting drugs is incompatible with recovery. That means that for heroin addicts to be in recovery, their sobriety date is when they last used any illicit or unprescribed drug, including alcohol and marijuana. Few treatment programs today think this way and even fewer enforce this broad no-use standard with frequent random drug tests. The losers from this more tolerant addiction treatment strategy are the patients who suffer more and longer from their addiction as a result of these lowered expectations and this lack of accountability.  

Physician health programs and EAPs
Bill White: In recent years, you have devoted considerable time to the study of Physician Health Programs (PHPs). What lessons can be drawn from the PHPs for the addictions field and for frontline addiction professionals?

Dr. DuPont: In 2005, I was frustrated by the failure of the leaders of addiction treatment to grasp the simple vision that seemed so obvious to me about how most addicted people get well and stay well. When I discussed this vision with colleagues, I ran into a brick wall: “Where is the evidence?” I struggled with that because it seemed so obvious to me. The “evidence” was all around everyone in the field. Look at the people who have overcome addiction and sustained recovery. They are everywhere in the country today, easily accessible to anyone who cares to look. But, no, that was not seen as evidence. I turned to my own practice where I had worked with many physicians over the years. There, I observed their experiences in their state PHPs. Although these programs had excellent results, there had been no national study to validate these outcomes.
For help, I turned to two long-time colleagues. Tom McLellan was the inventor of the Addiction Severity Index and the dean of treatment evaluation studies in the country through his role as Director of the Treatment Research Institute at the University of Pennsylvania. Greg Skipper was the distinguished head of the Alabama PHP and a leader in the PHP movement. Tom got funding for the study from the Robert Wood Johnson Foundation. Our biggest challenge was convincing the state PHPs that it was safe to collaborate with our group of outsiders to do this sensitive independent evaluation of their outcomes. Greg helped achieve this goal. Our study could not have been conducted without the sus­tained and energetic support of the Federation of State Physician Health Programs (FSPHP), a group I came to see as distinguished, dedicated and innovative program leaders.

Together, we achieved our goals, publishing a continuing series of papers documenting the outcomes of these programs. The most remarkable single statistic from this study came from the drug testing, which for these physicians was random, extensive and intensive. These addicted physicians were held to a standard of no use of any drug and no use of alcohol for five years or longer. That meant that each workday they called a phone number to see if they needed to submit a sample for testing that day. The tests were not the common five-drug screen but a 20-drug screen, including alcohol testing using EtG to identify alcohol use in the prior five to seven days. The results: 78 percent of the physicians did not have a single positive test for any drug or alcohol use over five years of testing. Of the 22 percent who did have at least one positive test, 65 percent did not have a second positive test. Where else in the addiction treatment field can you find results like that? Those results set an entirely new standard for recovery outcomes, one that every treatment program should aspire to. 

Bill White: Your study of the nation’s PHPs has influenced your thinking about drug treatment. Do you see areas where those ideas can have a wider impact right now?

Dr. DuPont: A recent study from SAMHSA showed that people suffering from addiction to alcohol and other drugs who were referred to treatment from the nation’s Employee Assistance Programs (EAPs) stay in treatment longer than those referred from and any other source including their physicians and self-referral. EAPs are powerful engines to identify drug problems early, to refer people to good treatment and to keep them there long enough for them to benefit from treatment. EAPs, like PHPs, manage care and use the leverage of the job to promote recovery.  I am proud that in 1982 Peter Bensinger, who headed the Drug Enforcement Administration (DEA) while I headed NIDA, created Bensinger, DuPont and Associates to provide employee assistance services.   

Lessons from clinical practice
Bill White: How important has your enduring clinical work been to your evolving views on addiction treatment and recovery?

Dr. DuPont: In my own practice of psychiatry since 1969, I have had the opportunity to work with many families over three generations. This intensive, long-term and highly personal perspective has been central to my evolving views on the nature of addiction and recovery. My patients have been my teachers and my inspiration.

In particular, they have taught me about the value of sustained participation in a recovery support ­program. I have come to see that the problem in addiction is not getting addicts to stop using drugs. Every alcoholic and every drug addict has been off alcohol and drugs many, many times. The problem in addiction is relapse, not withdrawal. Detoxification is not treatment. In fact, stand-alone detoxification is commonly a means for addicts to ­stabilize their drug addled lives so that hey can continue their addiction. De­toxification itself prolongs ­addiction.

What are the strategies available to an addicted person to maintain sobriety over a lifetime? Not treatment, that is for sure. Treatment is always short-term even at its longest—say a year or two, but more often a month or two. The disease of addiction to alcohol and other drugs, meaning the risk of relapse, is lifelong. Only the growing network of spiritual, religious and secular recovery fellowships meet that core need of addicted people. Those fellowships are lifelong, matching the disease as nothing else does. That profound truth I learned from the experiences of my patients.

Bill White: Could you give an example of any recent lessons you’ve learned about addiction recovery that have come from your private clinical practice?

Dr. DuPont: The hardest lesson for me is patience. I see plenty of people in the grip of addiction, caught in an abusive love affair with a chemical. Like anyone caught in an abusive relationship, they want to believe they can go back to their lover and that the next time, they will work it out. The therapist’s job is to convince them that the next time, the outcome will not be the same; it will be worse. Some of my patients get that right away, but many do not. I tell these skeptics two things. First, that I have completed this phase of my research on addiction, concluding that the problem gets worse over time. Clearly, they need to do more work of their own on addiction by living the painful disease. I caution them that they may die from it, and they are certain to suffer terribly and to extend that suffering to everyone who cares for them. But from that suffering they, and those who care for them, will learn eventually if they are not killed first. 

In my practice, I have seen many of the most hopeless cases of addiction descend into depths of suffering I can hardly imagine and for periods of time that seem impossible to endure, only to emerge, almost always with the help of the 12-step fellowships, into exemplary, happy and productive human beings. That experience helps me be patient and to never give up hope for lasting recovery. 

Future of addiction treatment
Bill White: As someone who has played an important role in the modern history of addiction treatment, what predictions would you make about the future of addiction treatment and recovery in America?

Dr. DuPont: Addiction is a powerful and pitiless teacher. I have no doubt that continuing to focus on understanding, preventing and treating addiction will prove to be an inspiring and rewarding quest for generations to come, as it has been for generations past. Few Americans know that the struggle to cope with the problems caused by alcohol goes back to the earliest years of our nation. The per capital alcohol consumption in the U.S. peaked in the first decades of the 19th century. The 20th century had a major focus on other drugs from heroin, invented in 1898 by the Bayer Company as an over-the-counter cough medicine, to cocaine and marijuana—all plant-based ancient drugs of abuse. More recently, the focus has shifted to synthetic drugs of abuse from methamphetamine to opiates, like oxycodone and hydromorphone. The one thing they have in common is their uni­quely powerful stimulation of the brain reward system and the thinking and actions that are triggered by that stimulation. The struggle to understand and reduce the problems of alcohol and drug abuse is more than 200 years old in the United States. Although these efforts have been successful beyond imagining, the challenge remains.

We have much yet to learn about this uniquely human disease. Put another way, addiction has much yet to teach all of us, our children and our grandchildren, often at very personal levels. Addiction is a uniquely human problem. I can confidently predict that in a hundred years, the problem of addiction will still be attracting a lot of attention and providing priceless lessons.    

Maintaining enthusiasm and passion 
Bill White: You have remained enthusiastic and passionate about your work in this field for more than four decades. Do you have any suggestions for the frontline counselor on how to not be overwhelmed by this work?

Dr. DuPont: My advice to counselors today: Learn from your patients/clients. Help them grapple with the cunning, baffling and powerful disease of addiction, a disease that is characterized by its hijacking of the user’s own thoughts and twisting their lives to fulfill the self-destructive purposes of the addicted brain, what I have called “the selfish brain.”Use your experience, strength and hope not only to help your patients/clients, but to help you understand your own life and the culture around you. Addiction is a door into every aspect of human knowledge from biology and psychology, to history and art.  

Health care is one of the most rapidly growing parts of the modern global economy. Unlike manufacturing and many other jobs, addiction treatment is not easily outsourced because direct human contact is at its heart. Counselors are the embodiment of health care for addicted patients. Most of health care is about mitigating, often marginally, the damage of diseases. In contrast to this experience, recovery from addiction to alcohol and other drugs is unique in two ways. First, the contrast between the degraded and miserable life of a using addict and the life of that same person in recovery is one of the most profound and glorious transformations not only in health care, but in the human experience. Second, the change produced by recovery from addiction is not merely the absence of the disease of addiction. Recovery is the development of an entirely new and a far better life. In other words, recovery is not about restoring addicts to where they were before their drug and alcohol use. Recovery is about profound improvements in life, in character, in relationships. That transformation is what keeps us in this field. That profound transformation, which we see every day, inspires us even as it helps us improve our own lives and our own ­characters. 

Bill White: If there was one more thing you could accomplish on behalf of the field of addiction treatment in the time remaining in your career, what would it be?

Dr. DuPont: I am a grateful “addict” to the field of addiction. My biggest hope and the goal of my remaining years is to share my joy with others and to thank those who have helped me along the way, especially my colleagues and my patients. I enjoy my life all the more knowing that however long it is, it will be very short. My advice for counselors working in addiction recovery—treasure every precious minute, not just the good times, not just the happy times. Pain, disappointment and rejection are all learning opportunities, growth opportunities for you and for your patients/clients. In my life, closed doors have been more valuable to me than open doors. The challenge I have learned is to seize even a few of the many opportunities that abound around all of us all of the time. 

Words for aspiring addiction professionals 
Bill White: You have spent more than four decades of your life working at all levels of addiction treatment in the United States. What advice would you give to the person considering addiction counseling as a career or to those who are just entering the field?

Dr. DuPont: Keep learning, keep growing. Addiction is a field filled with unending opportunities to learn and to help suffering addicts and alcoholics—and all the suffering people who care for them—including their counselors, who share their pain but who also have the perspective that from this suffering, can come a deeper knowledge and the promise of lasting recovery. That promise can only be achieved by hard work, guided by the motto “You alone can do it, but you cannot do it alone.” That is true for life, and it is surely true when dealing with addiction in yourself, in someone you love or in a patient/client.

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.

Janette, a 46-year-old woman who was recently divorced from her third husband, walked into a community mental health center with slurred speech, unable to make decisions, exhibiting extremely poor self-care and diminished expectations. All of her husbands were drug addicts; and the last one also was a sex addict (a term that was not readily used in the therapeutic process at the time). Janette was treated with antidepressants, and although she responded positively to the medication, she demonstrated a long-standing anxiety disorder. She fretted and worried about every minor and major detail in her life. Everything was a potential problem. Treatment with anti-anxiety medication improved her functionality. It was noted at the time of her intake that she was raised in a physically threatening, alcoholic home; and for a period of two years, experienced sexual abuse by two perpetrators who were friends of her parents.

Thomas started experiencing panic attacks shortly after he began recovery from his compulsive overeating. He was raised in an alcoholic family with a schizophrenic mother who subjected him to extremely cruel physical punishments. Food had always been his self-medication. Without the sugar, and without any recovery from the emotional pain in his life, his underlying fears quickly rose to the surface. He was hospitalized three times for what would ultimately be diagnosed as panic attacks characterized by intense anxiety, often accompanied by a feeling of impending death, heart palpitations, shortness of breath and sweating. He was never asked about his experiences growing up.

Both Janette and Thomas sought help in traditional settings that were not familiar with the dynamics of trauma or addiction. Although both experienced a stabilizing effect when treated for their presenting symptoms, the underlying issues were neither identified nor addressed. Ultimately, until the role trauma played in their belief systems and defense structures is recognized, the prognosis for a long-term favorable outcome is limited. Their trauma history will most likely continue to contribute to maintaining self-defeating belief systems and low self-esteem, resulting in poor decision-making and lack of healthy relational skills. That combination will, in turn, work against both of their potential for recovery from anxiety and depression, as well as Janette’s capacity to make healthier partner choices.

Familial trauma
When people think of trauma it is common to think of the trauma experienced by our soldiers in Iraq and Afghanistan, or the thousands of people who are survivors of natural disasters, such as hurricanes, tornadoes or tsunamis. Shoot­ings on our college campuses or in corporate offices leave behind many trauma survivors. However, the majority of people who experience trauma will experience a more subtle, chronic form that most often occurs within their own family ­system.

Blatant forms of trauma in the family include being subjected to and/or witnessing physical and sexual abuse. Trauma also occurs in more subtle forms—for example, living with fear on an ongoing basis, such as the fear of not knowing if or when a parent is coming home; or the fear that comes with listening to one’s parents argue night after night; or the fear of not being able to rely on a parent attending a significant event. To live with chronic fear during the vulnerable childhood and adolescent years—when one is developing beliefs about oneself and the world at large—is traumatic to emotional, psychological and spiritual development.   

For those who are familiar with the early years of the adult children of alcoholics (ACoA) movement, this work offered a model and a language that enabled people to understand their childhood experiences; and created a process for healing to occur. Post-traumatic stress disorder (PTSD), once called delayed stress, is what the “adult child” dynamic encapsulated. It offered a framework for how the vulnerability of children who live with chronic stress and loss, self-protect against their pain with a host of different defenses, while learning faulty beliefs and developing cognitive distortions in the process. PTSD then described the resulting consequences, which often would not present as problematic until many of these individuals were of adult age.

When intervening with those who were raised with addiction in the family, it is critical to address issues of chronic stress, chronic abandonment, and in some cases, blatant violence, all of which are aspects of trauma.

A 1999 report from the National Center on Addiction and Substance Abuse at Columbia University stated, “There is no safe haven for the abused and neglected children of drug- and alcohol-abusing parents. They are the most vulnerable and endangered individuals in America.” The report further noted that substance abuse causes or exacerbates seven out of 10 cases of child abuse or neglect, and that children whose parents abuse drugs and alcohol are nearly three times more likely to be abused, and more than four times more likely to be neglected (Reid, J., Macchetto, P. & Foster, S., 1999).

Callee, a 23-year-old client told me, “As I was growing up I really remember wanting only one thing, and that was to do it differently than how it was being done around me. Two days before my 23rd birthday, with my husband in jail for a drinking and driving charge, I looked into the passive eyes of my child, whom I had just thrown across the living room floor, and I felt my world and sanity crumble. I was doing it exactly as they had done.” Callee was raised with both substance abuse and physical abuse, and at a young age was quickly repeating her family script.

The culminating act of abuse is when someone is killed, but for many family members the physical abuse is not the hitting, slapping or punching someone until they bleed or are bruised; rather, it may be the shoving, pinching, slamming someone up against the wall until their teeth rattle or terrorizing car rides.

Also traumatic to a child’s development is the witnessing of abuse. Jake shared, “When I was about 10, Dad would regularly come home drunk about three in the morning and drag my 13-year-old brother out of bed. He’d be yelling things at him, slapping him about the face, making his nose bleed. Sometimes he’d beat him with his fists. My brother would be bleeding and crying and Dad would hold him up to the mirror and say, “Is this what a man looks like?” The tears and fear that filled my brother’s eyes were my tears and fear. I always wondered when Dad would come home and if it would be my turn for him to make me a man.”

While there is no substantiated causal relationship, addiction and sexual abuse frequently coexist in the same family. Children are primed for victimization as they:
• Are starved for attention—perpetrators are known to groom their victims, to initially engage a child under the guise of friendship and give them positive attention.
• Are less likely to speak up for fear of not being believed. They already live in a family system where the truth is not supported.
• Give others the benefit of the doubt.
• Don’t trust own perceptions.
• Have difficulty identifying their feelings, making it less likely they can use their feelings as cues and signals to propel them to action that may mobilize assistance.
• Are already confused about what constitutes appropriate boundaries.
• Are already experiencing shame (from the addicted family system), which then accompanies the added shame from the sexual abuse, fueling powerlessness rather than action (reaching out for help).

In addition to the more blatant forms of abuse, these children are often subjected to covert forms of sexual abuse; being called sexual names such as, “whore,” “slut,” or being asked if he or she got “laid” last night and then being laughed at in a humiliating tone; or being exposed to drunken nudity, which often reinforces negative statements to a child about his or her own body.

Even more prevalent is emotional and spiritual abuse within the addicted family. This may consist of verbal abuse, name calling, blaming or severe and cruel criticism. It is living with ­broken promises, lying and unpredictability—not knowing what will happen next. With this type of trauma comes a myriad of feelings, such as:
• Fear—of being with an under–the-influence driver; of divorce, or no divorce; that someone will get seriously hurt or die.
• Sadness—for the parent not showing up; for what the parent said or didn’t say to the child.
• Anger—for broken promises; for the message that the parent’s using is more important than the child; that the parent does not try to quit or is not able to quit.
• Embarrassment—for outbursts in front of friends; for the unkempt appearance of the parent; for what the parent said or did in public.
• Guilt—for thinking that they are responsible for their parents’ behavior; for having negative feelings for someone they are supposed to love.
• Confusion—about why this is all happening and who is at fault.

Children learn to tolerate the hurt. With continuing exposure, they come to expect it, often developing a greater tolerance for hurtful behavior. They succumb to the dysfunctional family rules—Don’t Talk. Don’t Feel. Don’t Trust. Don’t Think. Don’t Question—all in an attempt to cope. It is the Don’t Talk rule, the rule of silence, when people just pretend things are different than they really are that sits on top of all of the pain and dysfunction. There is no doubt that these are children raised with chronic stress.

Stress responses and trauma
The experience of stress can either promote growth or cause serious damage. There are three types of stress: positive, tolerable and toxic. Positive stress is associated with moderate short-lived physiological responses, such as the stress that comes with meeting new people, handling frustration, coping with parental limit-setting, etc. Positive stress is an important and necessary aspect of healthy development.

Tolerable stress is associated with physiological responses that could actually disrupt brain architecture, but are relieved by supportive
relationships, among other protective factors. These are stress situations such as the death or illness of a loved one; a frightening
accident; or a natural disaster. Certainly, these types of experiences can have long-term consequences, and they often become traumatic, particularly when coinciding with toxic conditions in childhood, which are traumatic in and of themselves. However, such stresses are emotionally and mentally tolerable when they are time-limited and the child has access to supportive people to provide buffering protection.

Toxic stress, the most threatening, is associated with strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of support. Toxic stress emerges in the face of loss—conditions of extreme poverty; continuous family chaos; persistent emotional, physical and/or sexual abuse; chronic parental depression; persistent parental substance abuse or other manifestations of addiction; and ongoing emotional or physical neglect. Without the protective factors that allow children the space to disengage, they become trauma victims.
Stereotypically, when we think of trauma, what comes to mind are public catastrophic events than can overwhelm an adult. What distinguishes childhood trauma from occurrences like combat stress is simply that the injuries occur to children. “Dear Lord, be good to me,” reads the epigram for the National Children’s Defense Fund. “The sea is so wide and my boat is so small.” A child’s personality and neurology—the little boat he or she must navigate in—are still developing.

For children, home is supposed to be safe. In times of trauma, the natural response is to run. This is not just about running from, but also of running toward. Trauma survivors typically run toward home, but where can a child go when the trauma is in his or her home? When it is not safe psychologically or physically to be the person you are, to own your truth, and what you see and how you feel, then you move into various trauma responses—you fight, you flee or you freeze.

Today we know the body cannot tell the difference between an emotional emergency and physical danger. When triggered, it will respond to either situation by pumping out stress chemicals designed to impel someone to flee to safety or stand and fight. In the case of childhood problems, where the family itself has become the source of significant stress, there may be no opportunity to fight or flee. For many children, the only perceived option is to freeze and shut down their inner responses by numbing or fleeing to the inside.

When young children get frightened and go into flight, flight or freeze, they have no way of interpreting the level of threat or using reason to modulate or understand what is happening. The brain’s limbic system becomes frozen in a fear response. The only way out is for a caring adult to hold, reassure, and restore the child to a state of equilibrium. When primary caregivers are not available to soothe and reassure, the child is left to live through repeated ruptures in his developing sense of self, his fundamental learning processes and his relational world.

By virtue of their extraordinary vulnerability, children are at special risk for trauma. Childhood injuries, even when mild by some people’s experiences, can have long-lasting effects because they occur while the very structures of the body, brain and personality are being formed.

The legacy  
Most children growing up in troubled families learn to function by developing a false sense of self, adapting to the needs and demands of the family system. The family legacy then continues as family members act out and cause spiritual and emotional bankruptcy. Most who are raised in a family with addiction or other painful circumstances are determined not to repeat history, and genuinely believe they are going to be able to do it differently.

While a trauma survivor may no longer be subjected to abuse, he or she may not have found a therapeutic avenue through which to resolve his or her pain. Survivors often try to cope and quiet the pain by using substances, such as alcohol, cocaine, methamphetamine, heroin or even food. Often their use of a medicating substance or high-risk behavior is in response to an anxiety disorder or depression. It is
common to see both addiction and co-occurring disorders among those with greater trauma histories. Addiction, depression and/or anxiety are common flight or fight responses, and certainly freeze responses among this population.

Another dynamic characteristic of trauma is the fact that it repeats itself generationally. While the names change, the stories of repetitive partnering with an addict are nearly universal. This is referred to as trauma repetition.

Usually something that took place in childhood and started with a trauma; reliving a ‘story’ from the past; repeatedly engaging in abusive relationships; or repeating painful experiences, including specific behaviors, scenes, persons and feelings (Carnes, P., 1997). It is often repeating what you know, the familiar or what you believe you deserve. It may be an attempt to change the outcome of an old family script. Ulti­mately, it is as futile as attempting to survive the sinking Titanic by repeatedly changing your seat as the ship is going down.  

The evidence
For more than a decade, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente in San Diego, along with leading researchers, have been conducting an ongoing study, the Adverse Childhood Ex­periences Study (ACE), to examine the childhood origins of many of our leading health and social problems. The ACE score is used to assess the total amount of stress during childhood and has unequivocally demonstrated and quantified for the first time that which we have observed clinically—as the number of adverse childhood experiences increase, the risk for the following health problems increases in a clear and progressive fashion (Anda, R. & Felitti, V., 2003):
• Alcoholism and alcohol abuse
• Depression
• Illicit drug use
• Risk for intimate partner violence
• Smoking
• Suicide attempts
• Multiple sexual partners
• Health-related quality of life—specific health issues of liver disease, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD) and sexually transmitted ­diseases (STDs).

In his book, The Truth about Depression, Charles Whitfield, MD summarizes 251 peer-reviewed published reports that examine the relationship of childhood trauma to subsequent depression and other mental illness. Of the 209 studies that linked depression with having a history of childhood trauma, the reports found that among those with a history of childhood trauma, depression was from 1.6 to 12.2 times more common than was found among the controls. Further, an additional 70 published studies from the community on nearly 70,000 trauma survivors and controls showed up to a tenfold increase in depression; and two prospective studies following 11,000 people for up to 20 years revealed an increase in depression of up to tenfold (Whitfield, 2003).

In his book, The Truth About Mental Illness, Whitfield cites a total of 153 data-based research studies that document the firm association of the link between alcohol and other drug problems and having a history of repeated childhood trauma (Whitfield, 2004).

The possibilities
The possibility for recovery from trauma begins with identifying whether or not there is a primary disorder and the potential for co-occurring disorders and multiple manifestations of addiction. In addiction treatment programs, it means recognizing family treatment is not merely an educational process, but that family members have the right and need the opportunities to heal from their ­familial pain.

For the primary clinician, it means asking clients about their original family history, asking pointed questions about the use of alcohol and other drugs, and exploring the possibility of other addictive disorders. It means asking about the possibility of physical or sexual abuses, and recognizing the impact of toxic stress, chronic loss situations and less than nurturing environments. And, in this process of asking, we as treatment professionals need to demonstrate a willingness to identify and address trauma as a clinical issue.

In some situations it is easy to not recognize the role past trauma continues to play in someone’s life. Or it may be easy to discount the role of trauma because the trauma itself or its apparent consequences may not seem to be as severe as someone else’s experience. But no one person’s losses negate anybody else’s experience. The prevalence and impact of traumatic experiences are not to be underestimated. Everyone deserves a life of choice versus living a script written by a dysfunctional family system.

Claudia Black, PhD is a well-known and respected educator and author of more than 15 books in the field of addictive disorders. She is Senior Clinical and Family Services Advisor for Las Vegas Recovery Center specializing in the treatment of chronic pain and substance abuse, and Senior Editorial Advisor for Central Recovery Press, publishing materials on addiction, recovery and behavioral health care topics. For more information contact lasvegasrecovery.com; centralrecovery.com; or claudiablack.com.


References
Anda, R. & Felitti, V. (2003). The Health and Social Impact of Growing Up with Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo. Centers for Disease Control and Prevention (CDC) and the Kaiser Health Plan’s Department of Preventive Medicine in San Diego, CA.
Carnes, P. (1997). The Betrayal Bond: Breaking Free of Exploitive Relationships. Health Communications, Inc. Deerfield Beach, FL.
Reid, J., Macchetto, P., & Foster, S. (1999) No Safe Haven: Children of Substance-Abusing Parents. Center on Addiction and Substance Abuse at Columbia University. New York, NY.
Whitfield, C. (2003). The Truth About Depression. Health Communications, Inc. Deerfield Beach, FL.
Whitfield,C. (2004). The Truth About Mental Illness: Choices for Healing. Health Communications, Inc. Deerfield Beach, FL.

This article is published in Counselor, The Magazine for Addiction Professionals, December 2009, v.10, n.6, pp.10-15. 

Editor’s Note: This article is the first in a two-part series on Neurofeedback in the Treatment of Substance Abuse. This article presents evidence of the neurological basis, specifically EEG dysfunction, underlying addiction that makes it such a complicated condition to treat, and explains how neurofeedback addresses cognitive, emotional and physical symptoms. The second part of this article will include a discussion of the efficacy models of neurofeedback and a review of the research applying neurofeedback to substance abuse treatment, as well as address the possible mechanisms of its effectiveness in addiction. 

Over the last two decades a new research and clinical approach—neurofeedback—has shown promise in the treatment of substance abuse. This article addresses how it works, what makes it so effective, why it is a potentially important tool in addiction, the neurophysiological issues it might address, the existing promising research and, most importantly, that neurofeedback can be a significant adjunct to the therapeutic and counseling process with addicts.

The category of disorders associated with substance abuse is the most common psychiatric set of conditions affecting an estimated 22 million people in this country (SAMHSA, 2004).  Furthermore, the disorder is accompanied by serious impairments of cognitive, emotional and behavioral functioning. These conditions and symptoms so significantly alter a person’s brain and its functioning, that we often refer to the drug as hijacking the brain, making it very difficult to think logically and appropriately weigh the consequences of the drug related behavior. 

Detoxified addicts have been shown to have significant alterations in brain electroencephalographic (EEG) patterns and children of addicts also exhibit EEG patterns that are significantly different than normal (Sokhadze et al., 2008, for review). This indicates that, not only are we dealing with the neurological consequences of drug-related behavior, but there appears to be a genetic pattern as well, that places certain people at greater risk for addictive behaviors. The complexity of these factors makes the treatment of addiction one of the most difficult areas of mental, emotional and physical rehabilitation. 

Multiple factors in addiction
Treating addiction is compounded by the many factors contributing to its onset and maintenance. Furthermore, the addiction itself masks many other clinical conditions that become more evident once the drug user becomes abstinent. In fact, it is frequently other psychiatric problems that lead to drug abuse as the addict attempts self-medication.  It has also been shown that people with cognitive disabilities are more vulnerable, and more likely to have a substance abuse disorder (Moore, 1998). These impairments appear to include attentional issues as well as the hypo-functioning of the frontal cortex, sometimes referred to as the executive brain, where decision making takes place (Fowler, et al., 2007).
As a result, we are learning that no one approach has all the answers. Multiple mechanisms require multiple considerations and approaches. In addition, addicts are a diverse group, resulting in the need for many tools and approaches. It appears that programs offering the most diversified array of treatment modalities are the most effective (Vaccaro & Sideroff, 2008). That is also why, for example, most programs urge the inclusion of a 12-step program for ongoing support. 

But how do you address the biological and genetic aspects while also addressing the traumatic and emotional factors, the social cognitive and attentional factors? How do you deal with the apparent “procedural memory” and conditioned factors that cause an abstinent addict, on his or her way home from work, to all of a sudden take an inappropriate turn and end up at the drug dealer? Neurofeedback appears to be a tool, a training that has the facility to address many of these factors associated with addiction. 

History of promising treatments
Over the years, there have been a number of developments that have been promising in the treatment of addiction. Each time a new approach is identified, it is immediately seen as being the long sought after “silver bullet” that will solve the addiction problem. This occurred with the development of methadone, and later Levo-Alpha Acetyl Methadol (LAAM). When I entered the field in 1976, as a post-doctoral fellow of the National Institute of Drug Abuse, Naltrexone was gaining popularity. Naltrexone is a long-acting opiate antagonist that blocks the effects of opiates, such as morphine, heroin and codeine.

It was around this time that the importance of addiction-related stimuli was becoming widely recognized (Wikler, 1984). In research examining the conditioned aspects of addiction, it was found that stimuli associated with the drug using behavior could serve as conditioned stimuli that would trigger an unconditioned psychophysiological response that had similarities to withdrawal and included anxiety, fear and physiological arousal (e.g. Sideroff & Jarvik, 1980). This conditioned patterning of response lead to the proposal that relapse liability might be determined by exposing addicts to these conditioned stimuli and monitoring their responses (Sideroff, 1980). 

Following this conditioning model, one potential mechanism of Naltrexone treatment would be the behavioral extinction of some of the conditioned associations of addiction.   In other words, if the addict attempted to get high while on Naltrexone, the lack of reinforcing effect might lessen the conditioned effects of drug related stimuli. This, in turn, might reduce readdiction liability. All that needed to happen was for the addict to use, without experiencing any effect; a perfectly reasonable theoretical assumption. So, not only was Naltrexone expected to be successful in keeping addicts from using, but it also could address conditioned aspects of addiction.

When I arrived at UCLA and the Veterans Administration at Brentwood in 1976, I was surprised to discover that the treatment program to which I had been awarded a fellowship, was already eliminated—almost before it began. With the help of the director of the methadone clinic, I started a new experimental Naltrexone treatment program, drawing recruits from the VA’s metha­done maintenance population. 

Unfortunately, Naltrexone did not meet its high expectations. While many methadone patients expressed interest in using Naltrexone, the long process of withdrawing from methadone—necessary in order to begin taking the opiate antagonist—eliminated more than 80 percent of volunteers. Also, as we enrolled volunteers, we found that 90 percent of  the addicts who began using Naltrexone never used opiates while on the antagonist; and the 10 percent who did use, only used once. It was as if the addict immediately experienced this “no reward” condition and thus didn’t bother to waste his money. This, in itself, was an interesting finding, as it showed this population to be able to demonstrate impulse control under certain circumstances (Sideroff et al., 1978). As a result, we never had the opportunity to test our theory of extinction.
The use of Naltrexone for opiate addiction has subsequently been viewed as an unworkable model. Yet, for the small fraction of individuals who were able to detox and begin taking Naltrexone, it did change their lives.

Typically, the “Silver Bullet” has been thought of in terms of a drug; something that could either eliminate craving or eliminate the high of the drug of abuse. What have become most useful, have been drugs of substitution, such as buprenorphine, (Johnson, et al., 2000), as we continue to search for an effective treatment combination that includes psychotherapy.

EEG and addiction
The EEG is one objective representation of how the brain is functioning. The EEG is recorded from scalp electrodes, and is a representation of electrical activity produced by the collective firing of populations of neurons in the brain, in the vicinity of the electrode.  Figure 1 presents a chart of brain wave frequencies and the primary functions associated with their production. It should be pointed out that this is a gross representation and that more precise differences—beyong the scope of this article - can be found when you look at specific single frequencies within each range. While all frequencies and frequency ranges are important and necessary, problems arise when there is too much or too little of a particular type of brain wave; there is difficulty shifting in response to changing needs; or the EEG is to reactive. 

For example, in a healthy functioning brain, if we look at the amount of theta being produced and we compared it (using 4-8 Hz) with beta frequencies between 13 and 21 Hz (cycles per second), there is approximately a 2 to 1 ratio. When we assess the EEGs of people with Attention Deficit Disorder (ADD), we see ratios that are 3 to 1 and much higher (Lubar, 2003).

These higher ratios indicate that the brain is producing too much of the slow waves relative to the beta waves, where the beta waves represent a more focused and engaged brain. In other words, these brains are under-activated. On the other hand, if we look at the EEG patterns of people with anxiety, worry and tension, there is typically too much activity occurring in the higher frequencies, usually between 24 and 35 Hz. The EEGs of people with substance abuse problems can show both of these patterns.

It has been demonstrated that the EEGs of addicts show specific abnormalities when compared to normative data. Studies of detoxified alcoholics indicate an increase in absolute and relative power in the higher beta range, along with a decrease in alpha and delta/theta power (Saletu, et al., 2002). Low voltage fast desynchronized patterns (high beta) may be interpreted as demonstrating a hyper arousal of the central nervous system (Saletu-Z et al., 2004); and Bauer, showed a worse prognosis for the patient group with a  more pronounced frontal hyper-arousal (Bauer, 2001).
The fact that these EEG patterns as well as alcohol dependence itself are highly inheritable further supports the biological nature of this disease (Gabrielli et al., 1982; Schuckit & Smith, 1996; Van Beijsterveldt & Van Baal, 2002).

These specific abnormalities show both a worse prognosis and a predisposition to development of alcoholism. Indivi­duals with a family history of alcoholism were found to have reduced relative and absolute alpha power in occipital and frontal regions and increased relative beta in both regions compared with those with a negative family history of alcoholism. In another study, these abnormalities also were associated with risk for alcoholism (Finn & Justus, 1999). 

It is a common belief that at least part of the cause of addiction is an attempt at feeling better—self-medicating. When someone with reduced or an absence of synchronous alpha rhythm takes a drink of alcohol, it results in the generation of an alpha rhythm or what is referred to as alpha synchrony, which a normal functioning brain has much greater capacity to produce (Pollock et al., 1983). Thus, it appears that the alcohol is helping the addicted person compensate for their brain’s inability to produce an alpha rhythm which is associated with a state of calmness. This mechanism helps to explain the use of alcohol by this group of addicts.

In related research on abstinent heroin-dependent subjects, it is interesting to note similar abnormalities of deficits in alpha frequencies, along with excessive high beta EEG activity (Franken et al. 2004; Polunina & Davydov, 2004). Although it appears that in some studies, these changes found in early abstinence normalize after several months of abstinence (Shufman et al., 1966; Polunina & Davydov, 2004). Cocaine-dependent subjects may show similar increases in beta activity, but in addition show increases in frontal alpha (Herning, et al., 1994). These changes, specifically the elevation of fast beta activity, appear to be correlated with relapse in cocaine abuse (Bauer, 2001). In contrast, meth­amphetamine abusers have been shown to have significant increases in delta and theta frequency bands (Newton et al, 2003).

There are many questions that this research does not answer with regard to the relationship between abnormal EEG patterns and addiction. For example, it is not known if these dysfunctional elements are coincidental or causal. In addition, these EEG patterns are found in many mental disorders, some that are typically coincident with substance abuse. These questions do not minimize the probable conclusions that the EEG dysfunction creates specific vulnerabilities of these subjects. For example, frontal alpha, which is also found with some types of ADD, results in impairment of executive functions, such as decision making; and excessive fast beta activity can result in excess emotional and physical tension as well, as obsessive qualities. 

Other substances of abuse have also been shown to correlate with abnormal EEG patterns. For example, studies have demonstrated that subjects with a chronic history of marijuana use demonstrate EEG patterns of frontal elevations of alpha frequencies. (Struve, Manno, Kemp, Patrick, & Manno 2003). This is referred to as “alpha hyper-frontality.” Another common feature of the EEG of chronic users is a reduction of alpha mean frequency, which may indicate some deficits in intellectual functioning.

Neurofeedback
Neurofeedback, as a subset of biofeedback, monitors a subject’s brain waves and feeds back selective information about these brain waves, in order to gain control over these patterns. Neurofeedback programs typically allow for the setting of thresholds within specific frequency bands or ranges so that when the EEG either rises above the threshold or drops below the threshold, some form of signal or reinforcement is presented to the subject. This feedback lets the brain know when it has been successful, thus, in an operant conditioning model, encourages this rewarded brain wave response. When the goal is to have the signal go above a threshold, we refer to this as “up training” or rewarding. When the goal is to reinforce signals that drop below a threshold, we refer to this as “down training,” or inhibiting this component of the EEG.

Joe Kamiya, a researcher at the University of Chicago, was the first researcher to discover that when a subject was informed that he was producing alpha brain wave frequencies, he would then be able to learn to detect, on his own, when he was in alpha (Kamiya, 1968). As a result of this finding, he designed a study in which he similarly gave feedback to the subjects as to their production of alpha, with the instruction to produce alpha. He found that when given this feedback, subjects were able to increase their production of synchronous alpha waves (Nowlis & Kamiya, 1970). Interestingly, his success led to the popularity of alpha training in mass culture, which coincided with its loss of credibility in the academic ­community.

Neurofeedback research and its acceptance took on a new impetus when Sterman, working with cats, was able to train these animals using a similar operant conditioning model, to increase the amount of synchronous spindle activity in the 14 Hz frequency range (Sterman, 2000). Since these spindles occurred over the sensorimotor cortex, he labeled them sensorimotor rhythm (SMR). These studies confirmed that the production of these brain waves—associated with motoric stillness—resulted in animals that were more resistant to the triggering of seizures. Sterman, then adapted this EEG biofeedback procedure with epileptic patients and demonstrated its effectiveness in reducing the frequency and intensity of seizures.

When a subject produces SMR activity, he is mentally alert with relaxed muscles (lower muscle tone). Lubar, working in Sterman’s laboratory, recognized the potential of this discovery, and in a series of research studies, he and his colleagues were able to train children with hyperactive disorder to increase their production of SMR activity with feedback, resulting in reduced hyperactivity (Lubar, 1985). 

The training procedures have evolved so that in addition to reinforcing SMR frequencies, the training of ADD also typically reinforces slightly higher frequencies of either 15 to 18, or 15 to 20 Hz activity, and at the same time, down trains the slower (theta) frequencies. The protocols address the ratio be­tween the slower (theta) brain waves, with the faster brain waves, with a goal of training greater activation of the brain, which translates into improved attention. In one follow up study, Lubar and associates were able to demonstrate that gains made in variables of attention were maintained in subjects 10 years following training (Lubar, 1995; 2003). 

At the same time that neurofeedback was being used to address attentional and cognitive deficits, primarily by training the activation of the brain, it also was being used to help people relax and establish autonomic and neuromuscular balance. With populations demonstrating aspects of anxiety, obsessive compulsive disorder and tension, the procedure has been to train increases in alpha frequencies (8-12 Hz) or a combination of alpha and theta (Moore, 2000). In these cases, the process is one of training a lowering of activation of the brain. A wide range of neurofeedback protocols have now been applied to cognitive, emotional and physical symptoms and conditions with a growing range of positive results. A bibliography covering these studies is available (Hammond 2008). 

Acknowledgement: The author wishes to express his appreciation to Eleanor Criswell, Jay Gunkelman, David Kaiser and Hugh Baras for their helpful comments.

Dr. Stephen Sideroff, PhD, is a licensed clinical psychologist, consultant and Assistant Professor in the Psychiatry Department at UCLA and one of the Clinical Directors at Moonview Sanctuary. Dr. Sideroff is an internationally recognized expert in behavioral medicine, biofeedback and peak performance, and wa the founder and former clinical director of Santa Monica Hospital’s Stress Strategies, which presented programsfor individuals and corporations to better cope with stress.

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Kamiya, J. (1968). Conscious control of brain waves. Psychology Today, 1, 56–60.
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This article is published in Counselor, The Magazine for Addiction Professionals, December 2009, v.10, n.6, pp.20-25. 

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

Underutilization of evidence-based treatment practices for addictive disorders represents a longstanding problem for the field, as well as for the public health of our nation. The Addiction Technology Transfer Center of New England (ATTC) at Brown University has adapted and implemented an organizational change strategy intended to support addiction treatment organizations and providers in the adoption and implementation of new treatment practices. 

Since 2003, the ATTC has worked with numerous community-based addiction treatment agencies in New England using this model, which is called the Science to Service Laboratory (SSL) (Gumbley, Duby, Torch & Storti, 2005; Squires, Gumbley & Storti, 2008). Survey data regarding satisfaction with the quality, organization and utility of the SSL have been highly favorable, and many of these agencies have successfully adopted new clinical practices. However, interesting organizational differences are apparent between agencies that have completed the SSL and those that have not. We discuss these differences, along with other results and future directions for the SSL. 

The science to service laboratory
The SSL is based, in part, on a model for transferring research to practice (Simpson, 2002; 2007), and is consistent with guidelines from The Change Book: A Blueprint for Technology Transfer (ATTC, 2004). A primary goal of the SSL is to enhance the perceived benefits of adopting new practices by working collaboratively with organizations and practitioners, while reducing issues of complexity (Rogers, 2003). It incorporates comprehensive training and support that relies heavily on interpersonal strategies; outside consultation; innovation “champions” who promote the benefits of change from within agencies; and collaborative problem solving around implementation issues. 

Principles of the Science to Service Laboratory. To improve attitudes about adopting evidence-based addiction treatment practices and to increase the corresponding knowledge and skills among stakeholders, the SSL is founded on several core principles detailed in The Change Book: agency interventions must be relevant to existing needs; introduction of interventions should be timely with respect to current needs; the process to communicate interventions should be clear (i.e. not complex); proponents of interventions should be ­credible; intervention efforts should be multifaceted (i.e. active and interpersonal); efforts to adopt interventions must be reinforced until they become routine; and communication between proponents of interventions and potential adopters should be bi-directional in order to facilitate issues and concerns that may arise during transfer efforts.

Collaboration with Technology Transfer Specialists. One key component of the SSL is the provision of a Technology Transfer Specialist (TTS) to provide ongoing technical assistance during the process of implementing a new evidence-based treatment approach. The primary role and responsibility of the TTS is to serve as an ongoing advisor to agency management and staff with the goal of increasing the likelihood of successful change efforts. A TTS at (or trained by) the ATTC meets several criteria, including: a minimum of a Masters Degree in counseling, education or related field; a minimum of five years of professional experience in either clinical and educational program development, implementation and management and/or supervision; demonstrated under­standing of the application of evidence-based practices; and experience working with state and federal agencies, academic institutions, community treatment programs and researchers in problem identification and resolution.

In-House Innovation “Champions”. In addition to close, ongoing collaboration with a TTS, and consistent with the noted importance of internal change agents located within organizations (Backer, 1995; Backer, Liberman, & Kuehnel, 1986; Rogers, 2003), the SSL emphasizes the importance of a point person, or innovation “champion” to serve as an internal catalyst for change within organizations attempting to adopt new technologies. Working hand-in-hand with the TTS, the innovation champion helps to harness and coordinate internal agency resources needed to support the SSL objectives.

Staff Training. Working in conjunction with the in-house innovation “champion,” the TTS facilitates staff trainings to cover the basics of learning and adopting a new clinical practice. Treat­ment staff is first provided with a basic ­introduction to the following topics: general characteristics of evidence-based practices, in general; a review of theories of change; a brief overview of the technology transfer process; and the importance of balancing fidelity and adaptation. One purpose of this training is to empower staff by actively involving them in the process of considering new practices. Second, and consistent with the idea of “bi-directional communication” between researchers and consumers of evidence-based practices as put forth by National Institute on Drug Abuse (NIDA), the SSL actively employs researchers from academic environments to conduct clinical training workshops and to provide follow-up consultative support to treatment agencies and their staff with respect to specific evidence-based clinical practices for which they have noted expertise.

Ongoing Support. Once all initial training is complete, a TTS continues to work closely with the agency to provide the following components: detailed follow-up information about the process of technology transfer; a forum in which issues relating to barriers, resistance, etc., can be addressed; assistance in the development of an implementation plan; and general support for the agency personnel who are serving as internal change agents.

Group Problem Solving. Research has shown that collaborative interpersonal contact can be critical in promoting the adoption of innovations (Backer, 1995; Backer et al., 1986). Therefore, the SSL also encourages and facilitates opportunities for individuals both within and across treatment agencies to engage in ongoing collaborative problem solving around issues of implementation.

Application of the Science to Service Laboratory
As part of an initial pilot project, the ATTC worked with 54 treatment agencies across all six New England states (CT, MA, ME, NH, RI, VT) to deliver the SSL. Each of the participating agencies initially submitted an application to participate, and were invited to attend a one-day “exposure” meeting to determine if the SSL would be relevant and timely for their agency’s needs.

Engaging Organizations. During the exposure meeting, participants were given a brief overview of the technology transfer process, which emphasized foundational concepts and rationale for the model.  In addition, they received a brief overview of a specific evidence-based practice for substance abuse treatment that would be used to model the training approach of the SSL. The evidence-based practice used for this purpose was contingency management (CM), and the initial presentations on this topic were given by a noted innovator in the field, Dr. Nancy Petry. CM was selected as a model intervention for the SSL based on it being a comparatively simple clinical method to employ with broad applicability across many treatment settings and substances of abuse (Budney, Higgins, Radonovich, & Novy, 2000; Higgins, Alessi, & Dantona, 2002; Petry & Martin, 2002).
Following the exposure meeting, agency directors were asked to designate three-member implementation teams for the project, and the director was asked to sign a statement committing the necessary staff and agency resources to complete the project for a period of up to nine months.
Technology Transfer Specialists. TTSs for the SSL included ATTC senior staff, or other individuals trained by the ATTC to fulfill this role with agencies in specific states. They were involved with or responsible for recruitment of participating agencies; conducting and/or coordinating all trainings; organizing inter-agency workgroups; and supervision throughout the duration of the SSL.

Bi-Directional Communication. Once the application and selection process was completed, regional staff trainings were scheduled to provide a one-day clinical workshop on CM, given by Dr. Petry. The CM workshop training provided staff with both an introduction to the principles and techniques of CM, and how to develop an implementation plan. Dr. Petry also worked with each TTS to develop clinical and supervisory skills related to CM. Agencies were encouraged to send members of their implementation teams (including the in-house innovation “champion”) and other staff considered significant to the implementation of the intervention to the regional trainings.

Organizational Work Groups. As noted, organizational workgroups have become an integral component of the SSL and the TTS has worked closely with innovation “champions” within each participating agency to establish a collaborative forum among staff to promote open communication and problem solving regarding the implementation of CM.  This venue also provided treatment staff with an opportunity for group supervision regarding fidelity of the intervention with both the innovation “champion” and the TTS. A particularly valuable aspect of the work groups was that they frequently included participants from multiple agencies, which promoted “cross-fertilization” of ideas. Finally, the TTS also worked closely with members of the organizational work groups to develop a written implementation plan (based on methods outlined in The Change Book).

General outcomes
Overall, more than half of the agencies (28) that began the project ended up completing all components of the SSL. Of those, 26 of the completer agencies (93 percent) adopted and implemented CM into clinical practice by the end of the roughly nine-month training period. Of the remaining agencies that did not complete the full SSL, most dropped out early in the process (following initial exposure and/or attempts to establish bi-directional communication), while the remaining agencies discontinued participation later in the SSL process (after having identified an internal innovation champion, but prior to developing and implementation plan). None of the dropout agencies implemented CM.

Satisfaction Surveys Regarding Participation in the SSL. A satisfaction and feedback survey was sent to staff members from each of the participating agencies, including those from dropout agencies. The purpose of the survey was to assess the perceived quality and utility of the SSL, as well as to solicit feedback about useful components and areas in need of improvement. Overall, 40 individuals (58 percent) from SSL completer agencies, and 16 individuals (43 percent) from SSL dropout agencies returned the survey within the requested timeframe. Re­sponses in terms of overall satisfaction with the SSL training, instruction, materials and experience were positive for both SSL completers and dropouts, and did not differentiate completer and dropout agencies. 

Additional Agency Characteristics. To further investigate why some agencies completed the SSL and successfully implemented CM, while others did not, despite universally favorable appraisal of the training model, we conducted a second survey designed to examine additional characteristics of completer and dropout agencies along two dimensions. The first dimension addressed how many, and which SSL components (exposure, commitment, bidirectional communication, identifying an innovation champion, training of implementation teams, development of an im­ple­ment­ation plan) dropout agencies completed before withdrawing from participation. The second dimension evaluated agency characteristics, including: management or staff turnover; personnel resources; financial resources; and whether or not there was turnover in the TTS assigned to a given agency. The purpose of the second dimension was to explore differences between completer and dropout agencies.

On average, dropout agencies completed only three of the six SSL components. As can be seen in Figure 1, there was a predictable decline in participation as time and required investment increased. While all dropout agencies participated in the initial exposure meeting, about two-thirds dropped out before identifying an internal innovation champion (see Figure 1). By definition, none made it to the final component of developing an implementation plan for CM.

We also compared the organizational characteristics data between the completer agencies that successfully adopted and implemented CM, and the remaining agencies that either failed to follow through with implementation despite completing the SSL; or dropped out altogether. As can be seen in Table 1, differences were largely in the expected direction. Non-adopter agencies reported higher rates of turnover (50 percent), with respect to an organizational management position key to the SSL effort (e.g. CEO, Program Director, Clinical Director) than did adopter agencies. Non-adopter agencies also reported a higher percentage of critical personnel (e.g. the internal innovation champion) turnover (42 percent vs. 31 percent), and TTS turnover (25 percent vs. 8 percent) than did successful adopter organizations. Unexpectedly, adopter organizations were more often observed as having insufficient financial resources (15.4 percent vs. zero) than non-adopter agencies; and there was virtually no difference between reports of adopter and non-adopter agencies’ general personnel resources (15 percent vs. 17 percent, respectively).

Adopter Agency Preferences. Finally, in the interest of exploring how we might further refine the existing SSL model, we conducted a six-question survey of directors across the 26 agencies that completed the SSL and implemented CM.  Each question had several choices that could be selected and ranked according to what would be most helpful. Of the adopter agencies queried, 16 returned completed surveys in the requested timeframe of two weeks. The questions and highest ranked choice for each were as follows:
1. What sources of information would be most helpful in identifying new evidence-based practices likely to meet the agency’s needs? Fifty percent of respondents endorsed “Professional conferences/workshops/seminars.” 
2. What aspects of new evidence-based clinical practices are most important to the agency?  Sixty-nine percent of respondents endorsed, “Relative advantage over existing practice.” 
3. What would be most useful to the agency in selecting a new evidence-based practice to adopt? Eighty-eight percent of respondents endorsed,
“A menu of practice options.”
4. What type of support would be most helpful in implementing a new evidence-based practice once one is identified? Forty-four percent of respondents endorsed, “Introductory skill training workshops,” with a range of three to 12 months of follow-up support. 
5. What types of follow-up information would be most helpful in evaluating the success of change initiatives? fifty-six percent of respondents endorsed, “Patient outcome data.”
 6. What areas are you interested in targeting for change within the organization?  eighty-one percent of respondents endorsed, “Adopting evidence-based clinical practices.”     

Discussion
Participants from all agencies (adopters and non-adopters) indicated a consistent and high level of satisfaction with the SSL. There were, however, several notable differences between adopter and non-adopter agencies in other areas. Most notably, non-adopter agencies had more frequent turnover in an organizational management position key to the SSL effort than adopter agencies (50 percent vs. 15 percent, respectively). Even among agencies that completed the SSL, the only two that did not actually adopt CM had experienced turnover in a position key to the effort, while the remaining 26 that adopted upon completion did not.

In addition to greater turnover among critical organizational management, non-adopter agencies also were rated as more likely than adopters to experience turnover among internal innovation champions (42 percent vs. 31 percent, respectively) and TTSs (25 percent vs. eight percent, respectively). Un­expect­edly, adopter agencies were more often assessed as having insufficient financial resources as compared to non-adopter agencies (15 percent vs. zero, respectively). This, however, may have been related to the nature of CM, in that adopter agencies were more likely to face financial challenges en route to implementing a viable CM protocol. Finally, while all of the adopter agencies signed a commitment letter confirming their initial intentions to complete the SSL, eight of the non-adopter sites failed to do so. While it remains unclear to what degree this reluctance was related to staffing instability or other factors, the finding is consistent with similar work done by Squires and Hester (in press) where initial agency willingness to sign a letter of commitment predicted retention in training.

Finally, questions designed for agency directors provided guidance on how the SSL might be refined in the future. Answers to these questions indicated that directors clearly preferred professional conferences, workshops or seminars as an initial means of identifying new evidence-based practices to be considered for future adoption. On the question of perceived advantages of new evidence-based practices, nearly 70 percent of directors endorsed “relative advantage over existing practice” as a first choice. This was not surprising given that relative advantage of new practices has been identified as a principal factor in determining adoption (Rogers, 2003).

When asked what would be most helpful to their organization in selecting a new evidence-based clinical practice to adopt, agency directors overwhelmingly (88 percent) selected a menu of practice options as their first choice. This finding is consistent with the literature on individual change, which has shown that a menu of change options, or offering more than one avenue to accomplish a goal, promotes positive outcome (Miller & Rollnick, 2002; Miller & Sanchez, 1994).  Once a new practice has been identified, nearly half of directors surveyed indicated a first choice preference of “introductory skill training workshops” to help in implementing the practice.  Beyond the first choice reported above, clinical treatment manuals, administrative technical support, and clinical supervision training/resources where also endorsed by over 50 percent of the sample.  Perhaps more than any of the others, the diversity of rankings on this item reflect the complexities involved in successfully adopting and implementing a new clinical practice, and they mirror the current literature on the topic. 

Finally, once change initiatives are undertaken, over half of directors surveyed indicated that “patient outcome data” was their number one choice in determining the success of implementing a new evidence-based practice, and that adopting evidence-based practices was the number one priority for change within their agency.

Conclusion
The adoption and implementation of new clinical practices in treatment agencies is a complicated, multi-faceted process.  Of all the findings reported, perhaps the most significant is the apparent and critical importance of staffing stability.  Given the high rates of staff turnover common in agency settings, it may be helpful for agencies considering significant change to identify and target a core group of committed individuals for any change initiatives.  It may also be helpful to offer specific incentives for participating staff to promote active, long-term involvement in the effort.  Our data also supports the potential value of expanding the range of options for practice choices, training experiences and follow-up support, and highlight the value of clearly identifying and communicating the relative advantage of new practices and how they relate to clinical outcomes.

Future directions

Building on findings from this project, we are working to incorporate additional resources into the SSL. First, we are developing comprehensive supervision and follow-up components that will better support clinical supervisors and link practitioners with clinical feedback resources following didactic training for a greater range of evidence-based practices. To that end, we are exploring ways to incorporate Internet-based resources that might include distance learning and interactive on-line supervisory and feedback forums, in addition to live training resources.  Second, we are collaborating with representatives from, and regional users of, the Network for the Improve­ment of Addiction Treatment (NIATx) model on ways to integrate SSL components to more comprehensively address and support organizational change for both business and clinical practices. Finally, we are working with a variety of local, state and regional agencies to integrate the SSL into practice. We also have a research grant from NIDA to experimentally evaluate the SSL as compared to “training as usual.” The study is nearing completion, and preliminary results are promising.

Dr. Dan Squires is a clinical psychologist specializing in addiction treatment, and Assistant Professor of Community Health at Brown University.  Dr. Squires’ academic work focuses on the dissemination of evidence-guided practices for the treatment of addictive behaviors. He is currently the PI/Director for the Addiction Technology Transfer Center of New England, and conducts research designed to evaluate comprehensive organizational change and training models for alcohol and other drug treatment organizations and providers.

Stephen J. Gumbley, MA, LCDP, has been working in addiction education, prevention, treatment and recovery since 1988.  He has served as clinical and programmatic administrator of a wide range of residential, outpatient and medication-assisted treatment programs. He is presently the Co-Director of the Addiction Technology Transfer Center of New England at Brown University.

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Squires, D.D. & Hester, R.K. (in press). Treatment provider perceptions and utilization of a PC-based brief motivational intervention for problem drinkers: Implications for dissemination.  Addictive Disorders and Their Treatment.

This article is published in Counselor, The Magazine for Addiction Professionals, December 2009, v.10, n.6, pp.30-35. 
 

There are lots of motivating factors for human behavior, including an intrinsic desire to achieve sobriety. One individual’s motivation for recovery may be to clear the tear out of a daughter’s eye, whereas another may be attempting to avoid a serious personal or work-related consequence.  
The chronic relapser who states ‘I didn’t get it till I did it for myself,’ probably didn’t get it because he didn’t want it; and when the time came that he did want it, he ‘got it.’ The person who has been an addict for much of his or her life usually does not possess a great deal of self respect, self-love or self-understanding at the point of treatment. “Why then would ‘I’ do it for me? I don’t even like me! Look at all the things I’ve done, all the pain I’ve caused. If anyone had done to me and mine what I’ve done, I’d probably shoot them!”

Another important point—the client who does have a sincere desire to ‘do it’ for himself, probably doesn’t need us to begin with; he is the one that goes to self-help or short-term treatment or neither and ‘gets it.’ It is in the best interest of our client to build upon whatever motivation he or she brings to treatment, as opposed to disregarding it in favor of our own motivator. Among the many treatment/recovery plans that we have developed for our clients—especially for the multi-treatment individual—one plan we often miss is ‘intrinsic motivation.’ That is, assessment of why the client is seeking treatment now; why he or she has sought treatment in the past; and what happens to the treatment motivators post-treatment.

The chronic relapser
The therapist asks Charlie, a chronic relapser, the following questions: why didn’t you call your sponsor?; and why didn’t you implement our agreed-upon relapse prevention plan or implement your newly learned coping skills? Charlie has been asked those questions before, and if he knew the answers, he probably would be ‘in recovery’ as opposed to ‘in treatment.’ Further, even when approaching Charlie’s multiple relapse/treatment history, using any number of models, such as DiClemente’s ‘Stages of Change’ (DiClemente, 2003) model; or adapting Miller & Rollnick’s popular and very effective ‘Motivational Interviewing’ (Miller, W. R. & Rollnick, S., 2002) style; traditional 12-step model; or even uncovering insightful psychodynamic treatments, don’t we (Charlie and the therapist) still insist that his lasting recovery depends ultimately on the answers to those above questions. Does our frustration stem from Charlie’s frustration, in attempting to provide explanations for these accusatory and shame-inducing questions? Again and again, Charlie states that he has no idea why he picked up (used drugs again); or he doesn’t understand why he seems to have no defense regarding picking up.

How do chronic relapsers usually perform in treatment? Do they usually complete treatment? Are they usually enthusiastic regarding their treatment? The answers: they perform great; they know the material front and backwards; they complete treatment, and usually are the best behaved and compliant of clients. And yes, they show up, once again, willing to endure all that’s required for initial sobriety and recovery. Given all this, our clinical responses often go something like this: “Oh boy, here’s Charlie again.  I hope the boss doesn’t give him to me!; “Did you see Charlie’s back for his spin dry?”; or “Charlie’s here for his three hots and a cot, again.”

Do you think Charlie knows how some of us feel? You bet he does; but our Charlie has something extraordinary, and if we are not looking we may not see or appreciate it. Charlie has almost unbelievable courage. In spite of multiple treatments, Charlie, once again, allows himself the opportunity to know recovery; and he trusts and allows us—in spite of our frustrating and seemingly hopeless work, with all the Charlies—to guide him, once again, along the path to that recovery.  

Yes, Charlie is courageous and he has an almost unbelievable desire to live in the freedom of recovery. How do we know this? Because Charlie keeps coming back! In fact, if we think about it, Charlie doesn’t really have a problem getting sober, since he has achieved that five, 10, 20 or more times (showing up at our door). So, if Charlie’s problem isn’t getting sober, what is it?  The easy answer, of course, is staying sober (or in recovery).

Charlie leaves treatment (residential and outpatient) with an aftercare plan firmly in hand and greets his life. Along with struggling to stay sober, he is facing legal, financial, family, health (Hep-C, HIV) and spiritual crises, and is in many ways, very immature.

Furthermore, Charlie experiences his life very differently than most folks. A combat veteran certainly experiences life very differently while in the midst of action, and for many, their life experiences may have changed them forever. A person with a chronic severe mental or physical disability certainly experiences the world differently than those who do not have disabilities. Isaac Newton, with all his brilliance, spent most of his life alone, contemplating the science of this world. I mention the above as examples of human beings that live in our world, very differently than most people. The issue here is that Charlie, like the examples above, lives in this world ‘differently’ than most of us ‘non-Charlies.’

Like us, Charlie views most everything through: his experiences (including family of origin, school, religion, culture, friends, etc); his reference points; his moral standards; his value system; and his emotive personal inventory. However, he also views everything through the eyes of an addicted person, with its legal, spiritual, cognitive, physical and all other learned and practiced consequences. Our Charlie (a so-called chronic relapser), lives as the addict he is, with all the attendant life demands and rituals addiction entails. He sees, for example, relationships as means to drugs; he sees other human beings (when he notices them at all) as means to drugs or threats to his drugs; he places no value in and only vaguely recognizes concepts such as, shopping, recreation, employment (especially career), home, parenthood, brother/ sisterhood, reader, writer, observer, hoper, futurist, historian, thinker or analyzer (except when it comes to the addiction).

Therefore, Charlie emerges from treatment with virtually every element of his life in acute crisis and only his life experience to help him deal with them. It’s nomystery why our Charlies relapse. Why not. That’s his life experience.

What seems a mystery is why Charlie keeps showing up for treatment. Especially if you do not subscribe to the prophesized reasons—‘three hots and a cot’ or Charlie just desires a ‘spin dry,’ or other such explanations for Charlie’s seemingly inexhaustible detox and rehab admissions. If you do subscribe to that thinking, Charlie, is not a mystery. His behavior is explained, and our job, frustrating and sad as it is, is redefined as: impossible.
Those of us not comfortable with such explanations for Charlie’s repeated requests for help have trouble understanding five, 10, 20 or more substance abuse treatments. How do we diagnose the inability for Charlie to regain control of his life and implement recovery strategies, when we know that Charlie has done this many times before? Are there any problem-solving or coping skills, relapse prevention or other education we can provide? Does Charlie need more referrals to psychiatrists, more or different anti-depressants, mood stabilizers, anti-anxiety drugs, Suboxone or other medications? Does Charlie need yet another halfway house, three-quarter house, sober house, new AA/NA sponsor, etc?

The answer to all of this is “yes”, probably a combination of many of these. However, Charlie needs to fully identify and understand why he ‘wants’ recovery. Sure he wants safety, at least for awhile; he wants three hots and a cot; he wants physical, emotional, mental and spiritual relief. Who wouldn’t want that after another drug run? But there are plenty of places to go for that (detox, missions, shelters, street outreach and other programs; and for some, friends and family can offer assistance). One does not need to seek out, participate in and comply with the rules and expectations of a treatment program to get food and shelter. We know that treatment is hard work. One program I participated in, as director of clinical services, was a 28-day rehab type city residential program. Clients were multi-treatment, multi-diagnosis, homeless addicts (45-bed male units and 32-bed female units, in different locations). It was and is a very intense program, providing seven full hours of treatment six and a half days a week (Sunday half-day treatment and visits). This doesn’t include self-help, family/couples work and other specialty program elements. Further, these programs are located in hospital settings (Moynihan, 2008).

Why would anyone voluntarily admit himself to seven hours of treatment daily, hospital food, dorm-style living and comply with very strict rules, including homework, just to get food and ­shelter. The demands on an addict participating in addiction treatment are enormous: self-searching (active addiction loves this—not); self-challenging (self-reproach, maybe); participation in group settings where one is expected to be forthcoming and honest (please); work with a clinician in individual sessions that require development of your treatment plan using your strengths, weaknesses, preferences,  introspection and insight (hmm); resisting the negativity of fellow campers in treatment (not to mention your own negativity), street thinking, fear, anxiety and of course, the old drug cravings. There also are other external demands from probation and/or parole officers, partners, and children. Again, this is not a complete list, but you get the point (hopefully)—substance abuse treatment, if it be of any positive consequence to the client, is enormously difficult and it takes a great deal of courage to face it the first time, never mind the twenty-first time. It’s becoming clearer to see why we use terms like ‘three hots and a cot,’ ‘spin dry,’ or the like, to explain why Charlie keeps showing up. It simply could not be to participate in seven hours of treatment every day, could it?

Yes, indeed it could! Earlier, Charlie was described as having something special: extraordinary courage. Charlie’s courage is demonstrated every time he wipes the tear out of his eyes and climbs back into the treatment ring to face his addiction, and every time he calls us to ask, “Can I come back in?” This brings us to the next question—what is the motivation supporting Charlie’s courageous attempt at recovery? Now, as we discussed, there could be any number of motivations (all valid) for our Charlies to enter treatment. These motivations could change over time for Charlie (stages of change) or the motivation could be the same for each treatment attempt.

We will define human motivation (HM) as: a human energy, not unlike instinct, but not instinct; rather, an evolutionary branch of instinct. HM provides us the energy to override our instincts, in favor of our personal growth. HM allows for strength in the face of weariness; hope in the face of despair, and courage in the face of historical failures. HM is that energy that propels one forward when one is instructed by instinct to remain in or achieve homeostasis.

A famous example: Tiger Woods may become the greatest golfer in history. “I refuse to let anyone out work me. That’s the reason I log so much time on the practice range . . . and I enjoy the process” (Woods, 2008). Most of us would think that is the last place he would go after playing in a four-day tournament. What motivates Tiger to that kind of dedication? It could be money, fame, pride, competition, self-improvement or something else, maybe. The point is when Tiger (or you) has the motivation to overcome his (your) instincts for safety, rest or comfort, reaching the object or goal of the motivation is always, to one degree or another, possible. Meaning, of course, that if Tiger does not achieve the status of ‘best ever,’ it will not be for lack of wanting it; striving for it; and developing and practicing the skills to ‘achieve’ it. What it does mean is that he has demonstrated a commitment to the object of his motivation that is truly inspiring to witness. Charlie, like Tiger, has the desire to reach his goal (sobriety). However, while Tiger’s intrinsic motivation allows him to overcome the pain of growth, Charlie’s intrinsic motivation, when needed most, has extinguished.

Everyone knows about motivation, and yet, no one really understands motivation. Sales managers motivate their sales staff; military officers and
non-commissioned officers (sergeants) motivate their troops; religious leaders motivate their flocks; coaches motivate their teams or individuals; and school teachers (especially the very effective ones) are constantly motivating their students. What is it these leaders are actually doing? Are they providing a source of energy for their charges to somehow plug into, or are they trying to stimulate the intrinsic human motivation (HM) energy reserve? Again, these HM energy reserves are similar to but separate from the instinctual energy reserves, such as the flight/fight energy. Helping an individual to find his or her reservoir of motivational energy to tap into will allow functioning in a non-homeostatic state (e.g., uncomfortable, scared, anxious, ashamed, etc.) while struggling toward the greater goal (in Charlie’s case, recovery).

It is absolutely clear that not all sales people, soldiers, religious folks, athletes or students, will perform at the same levels concerning their respective tasks. Other elements also are involved (desire, physical ability, prior learning, aptitude, mental physical spiritual disorders, life experience, etc.). However, each professional, in his own way, attempts to join the soldier, student or athlete, to that many times not understood and/or underutilized energy that is the directly linked to this phenomenon called human motivation. Simply put, motivating someone (to reach whatever goal) is an external effort to reach the individual’s intrinsic motivational energy.

Purposeful Motivational Intervention (PMI) is an adjunct therapy (to whatever model you choose to follow) to directly treat intrinsic motivation. Moving back to Charlie, proposed within is that Charlie shows great courage and motivation in his multiple attempts at recovery. In other words, Charlie is motivated for treatment. However, when Charlie graduates treatment, he is unable to sustain his motivation in the face of his various life struggles. Does that mean he does not want to successful negotiate these difficulties? No, it does not. What it does mean (given his multiple attempts at recovery) is that our Charlie has a deficit in his ability to reconnect with or maintain his intrinsic motivation. Charlie can no longer live in a state of imbalance (non-homeostasis)  while the crisis of conscious, judgment, fear, quilt, competence, etc. is present. Charlie relapses.    

Given this history clinicians need to seek out the components of Charlie’s lost connection to his intrinsic motivation. Does his motivation extinguish because of historical failures, re-emerged self-doubt, hate, fear, guilt or any number of other barriers to her energy reservoir? Please note, we are not talking barriers to behavioral issues related to initial recovery, such as getting to self-help meetings; getting alone with your boss; or taking your medications. Rather, we are referring to barriers to or deficits in the ability to access intrinsic motivation that would support ongoing recovery efforts while allowing for the emotional barriers. Everyone has these emotions at times in their lives, especially while under stress, but most don’t surrender to them and allow them to create havoc throughout their lives. If they did, the world would be even wackier than it already is. Bad things happen; I’m depressed; it’s unfair;  I’ve tried so hard—all are all normal, if unpleasant, thoughts and emotions. But what does that have to do with someone hurting himself (drugs/alcohol in Charlie’s case)? Nothing, that’s what; these things are all a part of the human condition! Again, the problem, so often, is the disconnect between an individual’s intrinsic motivational energy, that fosters growth in spite of difficult, seemingly impossible odds. One is lost to the circumstances, as opposed to energize to keep up the struggle. Make no mistake about it; there is no surrender in ongoing recovery. “Getting my life back,” is clearly a life and death battle. I may surrender or accept the fact that I can not drink/use in safety; that’s a great first step, and now, the fight to get ‘my life back,’ commences! Recovery is sustained by the energy of intrinsic motivation (IM), no matter what life throws at you. It is time for us to assess IM, recognize deficits and develop treatment plan accordingly.

Andrew J. Moynihan, PhD, LADC-1, LRC, CADAC  has worked in the substance abuse treatment field since 1985, at a detoxification center, 28-day programs, residential programs, shelter programs and forensic programs. He has held various positions, such as senior counselor, program director, executive vice president and clinical director. Currently, he has a private clinical practice and provides program development, including curriculum and consultation to various addictions treatment settings, as well as at training conferences. He has a special interest in human motivation, and believes strongly that it is a major component of change. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References
DiClemente, C. C. (2003). Addiction and Change. New York, NY: The Guilford Press.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change New York, NY: The Gilford Press.
Moynihan, A.J. Ph.D. LADC-1, LRC, (Director of Clinical Services). (2003-2008) hopeFound [formally Friends of Shattuck Shelter], Lemuel
Shattuck Hospital, 170 Morton St., Jamaica Plain, Massachusetts, 02130
Woods, T. (2008). www.tigerwoods.com, Tips: Article ‘Be honest; Where does your golf game need help’? (August 22, 2008)

There is no physical or psychiatric condition more associated with social disapproval and discrimination than alcohol and/or other drug (AOD) dependence (Corrigan, Watson, & Miller, 2006). Addiction-related social stigma constitutes a major obstacle to personal and family recovery, contributes to the marginalization of addiction professionals and their organizations, and limits the cultural resources allocated to AOD-related problems. Efforts to forge “recovery-oriented systems of care” inevitably confront social stigma as a barrier to shaping community attitudes and policies supportive of long-term addiction recovery. The purpose of this article is to highlight some of the modern research on addiction-related social stigma and outline actions addiction professionals can personally take to reduce such stigma within their communities.    

Stigma 101
Stigma Defined: Stigma is the experience of being held in contempt (shunned or rendered socially invisible) because of a socially disapproved status (Sayce, 1998). It involves processes of labeling, stereotyping, social ostracism, exclusion and extrusion—the essential ingredients of discrimination. There are three types of personal stigma:

• enacted stigma (direct experience of ostracism and discrimination, e.g., social rejection; professional disrespect; difficulty acquiring employment, housing or services; denial of governmental benefits—student loans, public housing, small business loans);

• perceived stigma (perception of stigmatized attitudes held by others toward oneself); and

• self-stigma (personal feelings of shame) (Luoma, Twohig, Waltzet al., 2007).    

Stigma and Recovery: Addiction-related social stigma extends to people who have achieved stable recovery from addiction (Tootle, 1987).  
Courtesy Stigma: The social stigma attached to addiction can be experienced by families, organizations (e.g., addiction treatment programs), neighborhoods and whole communities. Goffman (1963) referred to this stigma by association as “courtesy stigma.” The social stigma attached to families affected by addiction carries the implication that the family somehow failed to prevent this problem, contributed to its onset and/or played a role in failing to prevent or inciting relapse episodes. Children may be socially shunned due to the perception that they have been contaminated by the addiction of their parents or siblings (Corrigan, Watson & Miller, 2006).  

Multidimensional Stigma: The weight of addiction-related social stigma is not equally applied. Its burdens fall heaviest on those with the least resources to resist it, e.g., those for whom stigma is layered across multiple conditions (addiction, mental illness, HIV/AIDS, incarceration, minority status, poverty, homelessness) (Yannessa, Reece & Basta, 2008). Persons experiencing such layered, multidimensional stigma are less likely to seek addiction treatment than persons experiencing a single discredited condition (Conner & Rosen, 2008). The most intense social stigma attached to addiction begins at the point of admission to treatment (a social signal of problem severity) and intensifies with multiple treatment episodes (a social signal of treatment failure) (Luoma, Twohig, Waltz et al., 2007).

In the United States, the social stigma attached to illicit drug use varies by drug and method of ingestion, with use of heroin and crack cocaine being the most stigmatized substances and injection the most stigmatized method of ingestion (Surlis & Hyde, 2001). Greater addiction-related stigma may also be extended to people in particular treatment modalities. Stigma is particularly severe for persons whose treatment and recovery is supported by methadone, in spite of the well-established scientific legitimacy and effectiveness of methadone treatment (Joseph, 1995; Murphy & Irwin, 1992; Woods, 2001). Methadone-related stigma generates a wide span of discrimination—spanning employment, child custody, access to other forms of addiction treatment and even denial of the privilege to speak at some recovery fellowship meetings (Hettema & Sorenson, 2009; Joseph, Stancliff, & Langrod, 2000).

Stigma and Long-term Health: Stigma can elicit social isolation, reduce help-seeking and compromise long-term physical and mental health (Ahern, Stuber & Galea, 2007). Social stigma is a major factor in preventing individuals from seeking and completing addiction treatment (Luoma et al., 2007). Social stigma increases the service needs of persons with substance use disorders, but that same stigma decreases access to such services by fostering social rejection and discrimination (van Olphen, Eliason, Freudenberg, & Barnes, 2009).  
Personal Responses to Stigma: In­dividual strategies to deal with stigma include:

• secrecy/concealment  
• social withdrawal
• preventative disclosure
• compensation (using personal strengths in another area to counter the imposed stigma)
• strategic interpretation (comparing oneself to others within the stigmatized group rather than to those in the larger community); and  political activism (Shih, 2004).

Stigma and Cultures of Addiction: Individuals who share the “spoiled identity” of addiction have historically organized their own countercultures marked by distinct language, values, roles, rules (behavioral codes), relationships and rituals (White, 1996). These subcultures provide shelter from stigma; access to drug supplies; social support for sustained drug use; meaningful roles, activities and relationships; and mutual protection. Within these cultures, drug users protect their own identities by stigmatizing other drug users viewed as less in control of their drug use (Boeri, 2004; Simmonds & Coomber, 2009). Such attitudes can get played out within the social pecking order of drug treatment milieus. “Street cultures” also are imbedded with myths designed to inhibit treatment-seeking, contribute to ambivalence about treatment and increase the likelihood of treatment disengagement, e.g., street myths about methadone—“it rots your teeth and bones” (Rosenblum, Magura, & Joseph, 1991).

Strategies to Address Social Stigma: Three broad social strategies have been used to address stigma related to ­behavioral health disorders: 1) protest; 2) education; and 3) contact (Corrigan & Penn, 1999). One major strategy, seeking to inculcate the belief that alcohol and drug addiction is a disease, has not been consistently shown to produce sympathetic attitudes toward those with severe alcohol and other drug problems (Cunningham, Sobell & Chow, 1993). One of the most effective strategies to reduce social stigma is to increase interpersonal contact be­tween mainstream citizens and people in recovery (Corrigan, 2002). Contact between stigmatized and non-stigmatized groups as a vehicle of stigma reduction is most effective when this contact is: between people of equal­ status (mutual identification), personal, voluntary, cooperative and mutually judged to be a positive experience (Couture & Penn, 2003). Social stigma is particularly influenced by social proximity and distance. For example, community attitudes toward Oxford Houses are most positive among neighbors who live closest to these houses (Jason, Roberts & Olson, 2005). Reducing social distance and in­creasing interpersonal contact are important goals of any anti-stigma campaign.

Historical/Sociological Perspectives
Before exploring personal strategies that addiction professionals may use to address addiction/treatment/recovery-related social stigma in their own communities, it may be helpful to set this issue within a larger perspective.

Social stigma toward alcohol and other drug (AOD) addiction may be defined as an obstacle to problem resolution or as a strategy of problem resolution. The stigmatization and criminalization of alcohol and other drug problems in the United States has grown over more than two centuries as an outcome of a series of “drug panics” and resulting social reform campaigns (Jonnes, 1996; Musto, 1973). These campaigns have generated policies of isolation, control and punishment of drug users (White, 1979). Stigmati­zation is not an accidental by-product of these campaigns. It is a reflection of policies that “unashamedly aim to make the predicament of the addict as dreadful as possible in order to discourage others from engaging in drug experimentation” (Husak, 2004). An outcome of this complex social history is that many addiction professionals and recovery advocates see the stigma produced by “zero tolerance” policies as a problem to be alleviated, whereas preventionists see the stigma produced by such policies as a valuable community asset. A key question thus remains, “How do addiction treatment professionals, recovery advocates, and preventionists avoid working at cross-purposes in their educational efforts in local communities?”

Efforts to increase or reduce stigma attached to illicit drug use may have intended or unintended side-effects (Room, 2005). Two examples illustrate this point. First, efforts to decrease illicit drug use by portraying the drug user as physically diseased, morally depraved and criminally dangerous may inadvertently decrease help-seeking behavior by creating caricatured images of addiction with which few people experiencing AOD problems identify. Such strategies may also promote patterns of social exclusion and discrimination within local communities that block the ability of drug-dependent individuals to re-enter mainstream community life. Second, an anti-stigma campaign could inadvertently increase drug use if it normalized illicit drug use, increased non-user curiosity about drug effects, conveyed the impression that addiction treatment is an assured safety net (available and affordable) and that recovery is easily attainable, and glamorized the recovering addict as a heroic figure within cultural contexts in which few heroic models are available.  

Any campaign to counter addiction/treatment/recovery-related stigma must ask the question, “Who profits from stigma?” Efforts by one group to define another group as deviant can serve psychological, political and ­economic interests. Put simply, stigmatizing others often serves to increase the self-esteem of the stigmatizer (Tajfel & Turner, 1979). It elevates oneself as more worthy than the demeaned “other” and defines oneself as an upholder of community health and morality. Social scapegoating of others increases during periods in which personal esteem, security, safety, and social value are threatened. Partici­pation in or support of campaigns to define others as outsiders serves to confirm one’s own insider status. Addiction professionals seeking to reduce social stigma attached to addiction/treatment/recovery must address such issues of esteem, security, safety and social value.

  
Stigma has political utility. Anti-drug campaigns often mask and reflect deeper conflicts of gender, race, social class and generational conflict. Such issues have long been manipulated for political gain. Stigma is often the delayed fruit of anti-drug campaigns waged for the benefit of those seeking to build or retain political power. Anti-stigma campaigns must address the question of how the community and its political leaders can benefit from changes in attitudes toward addiction/treatment/recovery.

Social stigma can be fed by individuals and institutions whose economic interests are served by such attitudes. Changes in attitudes can trigger shifts in cultural ownership of alcohol and other drug problems and, in that process, shift millions of dollars in ways that affect the destinies of individuals, organizations and whole communities. For example, past changes in community attitudes have shifted millions of dollars between community-based addiction treatment and the criminal justice system. Such shifts influence the fate of professional careers, organizations, and in some cases, entire community economies. Similarly, what may be viewed as a problem of “not in my back yard” (NIMBY) prejudice by citizens of a particular neighborhood may actually reflect opinion being manipulated by hidden financial interests, e.g., developers who would profit from future gentrification of a neighborhood targeted for a new addiction treatment facility.

     
Social stigma attached to addiction/treatment/recovery involves complex issues, but each of us may find simple  steps we can take to help create a world in which “people with a history of alcohol or drug problems, people in recovery, and people at risk for these problems are valued and treated with dignity, and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated” (SAMHSA, 2002).

12 personal strategies
Addiction professionals and recovery advocates in the City of Philadelphia are engaged in a sustained conversation about addiction-related stigma. We are exploring how to best shape community attitudes and policies to transform the city into a true community of recovery. Some of the ideas we are hearing about how addiction professionals and recovery advocates can contribute to this effort include the following.
 1. Assess Yourself. Explore (self-inventory) how addiction-related stigma may have inadvertently influenced your personal (and your program’s) attitudes, beliefs and practices.
 2. Stay Recovery Focused.  Keep your own batteries charged by staying in touch with individuals and families in long-term recovery, e.g., attending open meetings of local recovery fellowships and/or recovery celebration events.
 3. Build Respectful Partnerships. Cultivate service relationships marked by respect, choice, and continuity of support.  
 4. Make Amends. Acknowledge and correct mistakes and shortcomings in your relation­ships with people who are seeking or in recovery.      
 5. Be a Recovery Carrier/Witness. Tell stories of individual and family recovery at every opportunity. The most singularly important thing you have to offer individuals, families, and your community is hope.
 6. Walk the Walk. Conduct yourself in the community as an ambassador of the recovery movement, conveying as best you can such core recovery values as humility, honesty, gratitude, respect, tolerance, responsibility and service. Never forget that people will judge those you serve, your organization and your profession by how you conduct yourself in the community.
 7. Model Non-stigmatizing Language. Use language that is medically descriptive rather than moralistic, e.g., “addiction,” “drug dependence,” or “substance use disorder” rather than “drug abuse.” Refrain from language that equates methadone with heroin, e.g., avoid references to methadone treatment as a “substitution therapy” or “replacement therapy” (Maremmani & Pacini, 2006). Use “person first” language in inter-professional and community-level communications, e.g., “person with a substance use disorder” or “person experiencing drug-related problems” rather than “substance abuser” or “addict.” Confront language in the treatment milieu that demeans and objectifies, e.g., references to persons re-admitted for treatment as “frequent flyers” or “retreads.”    
 8. Educate Yourself. Seek educational opportunities to increase your knowledge about addiction, treatment,and recovery—particularly on subjects about which you have great passion but little education. Passionate opinion in the absence of knowledge is not an admirable trait of the addictions professional or recovery support specialist.  
 9. Be an Educator. Seek out opportunities to educate allied professionals, other community service workers, and the larger community about addiction, treatment, and recovery. Use encounters with addiction/treatment/recovery stereotypes in the community as educational opportunities, but be careful to speak only within the boundaries of your education, training, and experience. It is far better to declare, “I don’t know” than to convey an ill-informed opinion.
10. Extol the Honor of Service Work. When talking about your work with other professionals and members of the community, emphasize points that will enhance optimism about long-term recovery and the importance of, and personal satisfaction that can be drawn from, professional/personal support of long-term recovery efforts.
11. Be an Advocate. Speak out against stigma-related discrimination, e.g., in housing, employment, government benefits, access to health and human services and in stigma-shaped policies/practices within addiction treatment.
12. Embrace and Promote Diverse Pathways for Recovery. Avoid polarized “either/or” debates about the way to treat addiction or the way to recover. Our best message is: There are many pathways to addiction recovery, and all are cause for celebration.  Help people see that there are others like themselves in recovery who share their world view, whether that view reflects a secular, spiritual or religious orientation.  
13. Challenge Institutions. Don’t assume that institutions in the treatment field or that should otherwise “know better” don’t stigmatize people in the same way that the broader society does.  Stigma is pervasive and the attitudes of even well-meaning individuals and institutions may unconsciously reflect such stigma.  
14. Join the Movement. Participate in local recovery advocacy organizations and grassroots anti-stigma campaigns. Contribute your time, talent, and money to support such efforts.  (See www.facesandvoicesofrecovery.org)

Closing reflection
The social stigma attached to addiction exists at cultural, institutional, interpersonal and intrapersonal levels; potential antidotes to such stigma must work at these same levels (Woll, 2005).  

Too many of us hide within our own professionally and socially cloistered worlds while boldly challenging our clients to re-enter the life of communities from which we have long been disengaged. We need to re-enter those communities and stand in partnership with those we serve to confront the social stigma attached to addiction/treatment/recovery. It is not enough to personally help each client initiate a recovery process. We need to assure a community/world that welcomes and nourishes such recoveries.   

As part of our larger recovery-focused systems transformation process, the City of Philadelphia is exploring development of a long-term strategy to reduce the stigma attached to addiction/treatment/recovery. Other communities across the country are involved in similar efforts. We hope this opening discussion will stimulate your own thinking about how you can contribute to this movement.   

William 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. Arthur Evans, Jr. is Director of the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBH/MRS).

Roland Lamb is the Director of the Office of Addiction Services, Philadelphia DBH/MRS.  


References
Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88(2-3), 188–196.
Boeri, M.W. (2004). “Hell, I’m an addict but I ain’t no junkie”: An ethnographic analysis of aging heroin users. Human Organization, 63, 236–245.
Conner, K.O., & Rosen, D. (2008). “You’re nothing but a junkie”: Multiple experiences of stigma in an aging methadone maintenance population. Journal of Social Work Practice in the Addictions, 8(2), 244–264.
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