By Daniel Jordan
General Manager
Sunshine Coast Health Center

One of the benefits of residential treatment is the many opportunities that clinical staff have to get acquainted with clients. Having a laugh over lunch, chatting during breaks, and working through issues in structured group and individual therapy allows our clinical staff to learn a lot about the clients they serve. Getting to know our clients so intimately also affords a greater appreciation of the complexities and challenges inherent in addiction and it’s treatment.

A few months back, the clinical team at Sunshine Coast Health Center took an informal poll and found that approximately 3 out of 5 clients were, prior to treatment, acting out sexually. Interestingly, clients rarely, if ever, made any mention of sex addiction on their admission form. Instead, clients come forward after concluding during treatment that their acting out sexually seemed to have a lot in common with their addiction to substances. While we know that individuals with one addiction often have multiple, or concurrent, addictions we underestimated it’s prevalence. As a result, steps were taken to enhance the skills of the clinical staff to treat sex addiction, culminating in a 2-day on-site workshop September 17 & 18,  2009. * Hosted by sex addiction expert Robert Weiss, this event marks an important first step in expanding our program to include process addictions such as gambling, sex, eating disorders, and online gaming.

However, while training staff on process addictions is a step in the right direction, we know that implementation is another matter entirely. Therefore, as a program more accustomed to treating drug addiction and alcoholism, Sunshine Coast Health Center is proceeding with caution,  carefully weighing the costs, benefits, and challenges of treating process addictions. An important first step is, I believe, looking at how we, as a treatment center, define addiction.

(*) Note: for more information on the 2-day sex addiction workshop see our promotional flyer.

DEFINING ADDICTION

Addiction is a complex condition that can be defined by it’s etiology, by it’s symptoms, and by its scope.

Defining Addiction by Etiology

In my last article, We Were Powerless Over Our Addiction: Why Step One is So Controversial, I alluded to competing theories on the causes of addiction. Often times, people will define addiction by its etiology, for example, “addiction is a brain disease” or “addiction is a psychological maladjustment or negative coping skill”, etc. However, as important as the origins of addiction may be, this blog article is not about etiology.

Defining Addiction by Symptom Severity

Addiction can also be understood by the severity of its associated symptoms. For example, previous blog articles have introduced the 3 Cs: a self-test that people can use to help figure out whether or not someone has crossed the blurry line between misuse and addiction. To review, we distinguish addiction from a bad habit based on the 3 Cs. This simple test can be applied to any substance or activity:

C#1 - Compulsion - obsessive thinking about, and planning around, a substance or activity so that an individual has regular, convenient access. Compulsion is what happens during the abstinence stage of the cycle.

C#2 - Control - an inability to control the amount of time engaged in an unhealthy activity, or the amount consumed of a harmful substance, once initiated. Control is what happens during the active stage of the cycle.

C#3 - Consequences - repeated engagement in an unhealthy activity or harmful substance despite negative consequences. Often times the Consequences stage is motivation enough to return back to the abstinence, or compulsion, stage.

If a person is observed exhibiting behaviour described in C#1 and C#2 but not C#3, chances are then they are probably still just at the abuse stage. Most abusers will stop or cut back once they experience one or two negative consequences such as a DUI charge, failing grades, or problems at home. Therefore, C#3, consequences, is what distinguishes addiction. Another way of explaining consequences is that addiction is, by it’s very nature, a state of chronic relapse.

However, while it’s important to distinguish addiction from abuse, this blog article is really about how we define the scope of addiction, or the different types of substances and activities normally associated with addiction.

(*) Note: For more information see The 3 Cs of Addiction Test: Are You Addicted?

Defining Addiction by Scope

It was not that long ago that the term “alcoholism” was the predominant term used in addiction treatment circles. According to Hazelden Foundation, one of the first residential treatment programs in North America, it wasn’t until 1958 that their clinical staff recommended using a new term, “chemical dependency,” to replace ”alcoholism” to better reflect the growing trend of marijuana, cocaine, and heroin misuse in the United States. *

Fifty years later, it’s not just illicit drugs but prescription drugs and it’s not just substances but activities, or “processes” such as gambling, sex, online gaming, and eating disorders. However, while the term “addiction” is now in common use (more so than “chemical dependency”), the vast majority of residential addiction treatment centers in North America still focus almost exclusively on drugs and alcohol. Admittedly, our own website and printed literature reflects that we, too, are first and foremost a chemical dependency treatment program. Why, then, has the addiction treatment industry been reluctant to include process addictions?

(*) Source: Hazelden History

THE CHALLENGE OF TREATING PROCESS ADDICTIONS

As mentioned earlier, Sunshine Coast Health Center is in the initial stages of reorganizing our treatment program to include process addictions. During this transition, however, we recognize the challenges involved.

Challenge #1: Lack of Evidence-Based Treatment for Certain Process Addictions

Until recently, the vast majority of addiction research and program development has focused on chemical dependency. In his landmark book first published in 1983, Out of the Shadows: Understanding Sexual Addiction, author Patrick Carnes became one of the first to link unhealthy sexual behaviour to addiction. Twenty-five years later, pornography, particularly online porn, has become a multi-billion dollar industry.

Furthermore, although gambling addiction has been recognized for a long time, very little research has surfaced for the treatment of gambling addiction. This is somewhat puzzling considering the growing dependence of provincial governments on gambling revenues.

Challenge #2: Lack of Consensus on Whether Certain Processes Are Addictions

Another consideration for addiction treatment providers is the lack of consensus about whether anything that is vital to the survival of the human race, such as sex and food, could be considered addiction. For example, sexology proponents argue that much of what is considered sexual addiction is normal sexual behaviour, essential for healthy sexual development and the survival of our species. Other experts believe that sexual addiction is actually a mental illness commonly referred to as obsessive compulsive disorder and refer to it, not as an addiction, but as sexual compulsivity.

Challenge #3: Lack of Medical Care to Treat Eating Disorders

While individuals struggling with eating disorders have had access to specialized treatment, these programs are scarce and are typically government outpatient programs or private residential programs in the US. A reason for the paucity of programs is the long-term medical intensity required to treat moderate to severe eating disorders, particularly anorexia and bulimia nervosa. Eating disorders can be life threatening and require medical monitoring and procedures not typically offered in residential alcohol and drug rehabilitation programs.

Challenge #4: Impact on the Peer Group

Another concern of programs that specialize in chemical dependency treatment is the impact that individuals with other addictions will have on the peer group. While it is quite common for individuals with drug or alcohol addiction to have concurrent gambling, sex addiction, or, to a lesser extent, eating disorders, there is a prevailing notion that people who are exclusively processed-addicted may not be compatible with the dominant, chemically-dependent peer group.

Some treatment centers address this concern by creating separate tracks for process addictions. In other words, someone with a sex addiction will be placed in a group separate from those with chemical dependency and will have their own group therapist. However, the problem then becomes costs associated with extra staff, creating a sense of separation in the peer group, and adverse group dynamics associated with insufficient group size.

Then there is the challenge to the peer group of having an individual whose sexual behaviour crosses over into sexual offending such as pedophilia, compulsive masturbation, incest, and rape. Incidentally, sexual offenders will be a major topic in our September workshop.

Challenge #5: Lack of Clearly Negative Consequences for Some Process Addictions

Unlike chemical dependency, gambling, or eating disorders, individuals with sex addiction or online gaming addiction show symptoms that may seem less harmful. Therefore, the perceived need for treatment may not be as obvious. * 

(*) Note: For addition information on the negative consequences of online gaming see Ambivalence is Fertile Ground for the Growing Popularity of Online Gaming.

Challenge #6: Apparent Lack of Demand

For all of the publicity that certain process addictions have been getting recently, most residential treatment centers do not receive a lot of calls for gambling, sex addiction, or online gaming. This apparent lack of demand may be attributable to the more benign effects of certain process addictions (see Challenge #5 above), the lack of available funding for individuals with gambling addiction, the lack of perceived similarity between process addictions and chemical dependency, or the greater stigma attached to sex addiction.

Challenge #7: Training Clinical Staff

Addiction, particularly process addiction, is rarely taught in graduate or medical school. Professional development workshops rarely offer courses in process addictions. Training, therefore often requires that staff travel to the United States or that a presenter be brought up for training on site. Sunshine Coast Health Center chose the latter because all of our clinical staff needs training, not just one or two counsellors. Any way you slice it, it’s expensive and is tricky to schedule in a 24/7 residential program like ours.

Sunshine Coast Health Center is also interested in training the staff of gambling addiction, however, we have been unable to find an expert in this field. WIth regard to eating disorders, management is unsure if the  demand for men’s eating disorder treatment is sufficient to justify the costs associated with specialized staff training (not to mention the possibility that additional medical staffing or equipment may be required).

Challenge #8: Establishing Clear Admission Criteria

Before we begin to admit clients who have a process addiction without concurrent chemical dependency, clear admission criteria must be established. For example, where do we draw the line on the severity of a process addiction? The challenge of sex addiction that has crossed over into sexual offending is a good example. Fortunately, this aspect of sex addiction and its treatment will be addressed in the upcoming Robert Weiss workshop.

Challenge #9: Tailoring the Program to Address the Unique Aspects of Other Addictions

Part of treating other addictions is to first differentiate their unique aspects then to integrate new treatment techniques or knowledge into a program that embraces these differences but includes the effective components of previous modalities.

Fortunately, for Sunshine Coast Health Center, our smaller size and favourable counsellor-to-client ratio allow us to provide a higher degree of individualized treatment than what’s possible in larger facilities.

WHY SUNSHINE COAST HEALTH CENTER REMAINS COMMITTED TO TREATING PROCESS ADDICTIONS

With all of the challenges present in integrating other addictions into chemical dependency treatment, one could be excused for maintaining the status quo. However, Sunshine Coast Health Center is committed to expanding our treatment of addiction to include process addictions. If one considers the needs of the addicted client, there are a number of good reasons for making the change.

Reason #1: Risk of Drug or Alcohol Relapse

Clients who abstain from drugs or alcohol but continue to participate in process addictions run the risk of eventually relapsing back to their drug of choice.

Reason #2: Living Out of Integrity

Clients who abstain from their drug of choice may be considered by some programs to be a treatment success. However, at Sunshine Coast, abstinence is only part of what is considered true recovery. The clinical program at Sunshine Coast emphasizes personal integrity, being true to one’s sense of self. Shifting to another addiction precludes developing inner strength and authentic connectedness to others, particularly family.

As Geoff Thompson, Sunshine Coast Program Director, often tells clients, “it’s not in the bottle.” Including individuals with process addictions in the peer group will help chemically depend clients understand that, even in the absence of drugs or alcohol, individuals can still have addictions. Process-addicted clients, therefore, are living proof that drugs and alcohol do not have some sort of magical, addictive property.

Reason #3: Reducing Client Shame Associated with Their Addiction

By identifying with individuals that have different addictions but find themselves in similar circumstances, clients may come to see that addiction manifests itself in many ways in our society.

A few months back a therapist explained her philosophy of addiction. To summarize her approach, she explained that “all human beings are in recovery from something.” Our talk has stuck with me because I see how all human beings have moments of insanity as defined by Albert Einstein: doing the same thing over and over again and expecting different results.

As Christina Grof writes in her book, The Thirst for Wholeness, “By recognizing that as human beings, we share the common dilemma of attachment, but to different degrees, we open the way for understanding and compassion toward ourselves and others. We can even discover a sense of relief and liberation as we recognize the reality of our mutual dilemma.” The AA spiritual principle of surrender is closely linked to addiction and attachment. Just as recovery from addiction is made easier by surrender, so freedom from attachments also requires surrender.

CONCLUSION

As mentioned in this article, Sunshine Coast is hosting a 2-day workshop hosted by sex addiction expert, Robert Weiss of the Sexual Recovery Institute based in Los Angeles. Out of this training, we hope to make some important distinctions between sex addiction and chemical dependency, as well as the difference between a sex addict and a sexual offender. It promises to be an engaging two days.

As part of our new program at Sunshine Coast Health Center, the idea that addiction is strictly a substance-related phenomenon is coming under scrutiny. Clients with multiple addictions require treatment that recognizes the complexity of their predicament. However, just as mental health issues can complicate treatment, treating multiple addictions at the same time is the best approach to take, despite the additional challenges to staff and program. For the time being, clinical staff believes that treating both chemical dependency and process addictions with clear, thoughtful admission criteria, will mean better treatment and, thus, better outcomes for the clients we serve.

Yesterday, Oprah Winfrey dedicated a segment on her TV show to severely obese children. A 14-year-old girl interviewed in the middle of a food binge confessed that “once she starts she cannot stop.” She went on to say that when she starts to feel down about herself, she eats. I know more than a few kids that find the same sort of relief through online gaming. Hopefully, other private and government addiction programs will also consider expanding their notion of addiction to include process addictions. Now, more than ever, it’s clear that addiction is more than just a ’skid-row’ phenomenon.

By Daniel Jordan
General Manager
Sunshine Coast Health Center

Earlier this week, I had a thoroughly enjoyable discussion with Paul Murray, a private-practice psychologist based out of West Vancouver, British Columbia. Our discussion covered a lot of ground but one topic that I found particularly engaging was the notion of powerlessness. Both Paul and I marvelled at how two people declaring powerlessness over their addiction may have two very different treatment outcomes based on fundamentally opposing underlying intentions: one may reflect a preference for the status quo while the other could be ready to turn over a new leaf.

How Powerlessness Became Synonomous with Addiction

Obviously, this idea of powerlessness is not something that Paul and I invented. As friends of Bill W. will tell you, powerlessness lies at the heart of the 12 Steps of Alcoholics Anonymous and it’s first step: We admitted we were powerless over our addiction - that our lives had become unmanageable. Al-Anon has also consoled family members for years by telling them that they, too, are powerless over alcohol.

Over the years, however, Alcoholics Anonymous and other 12 Step programs have had their fair share of critics with powerlessness frequently at the heart of the dispute. For example, SOS, has created an alternative self-help group for “… those people who find that the ideas of reliance on a Higher Power or God, “powerlessness” and the emphasis on character defects to be an obstacle to recovery.”

The addiction treatment community has long since argued for and against the notion that individuals with addictions are ’powerless’. Powerlessness proponents tend to be traditional 12 Step treatment programs, physicians, and psychiatrists while those opposed tend to be psychologists, scholars, and mental health practitioners. The ongoing debate between these opposing camps has only hampered efforts by moderates to find common ground.

Furthermore, the debate over powerlessness and addiction is more than just a trivial concern judging by the vitriol one hears expressed on talk-back radio programs.

Defining Powerlessness

Let’s consider five different ways that powerlessness is understood in relation to addiction:

1) Powerlessness is a Choice

Recently, a book by Harvard psychologist Gene M. Heyman (*), Addiction: A Disorder of Choice, has suggested that individuals choose to be powerless. Dr. Heyman argues that addiction is voluntary rather than compulsory, and that addicts respond to incentives just like most other people. According to Dr. Heyman, interviews with drug users in recovery shows that quitting was preceded by such factors such as finances, family, career, and health.

People who suffer from diseases such as Alzheimer’s or schizophrenia, however, will rarely find improvement in their condition due to good intentions, even when followed by concrete steps. In other words, human beings are only truly powerless when faced with ‘real’ diseases.

One important difference between Dr. Heyman and other opponents to the concept of powerlessness, however, is that while Dr. Heyman believes that to remain powerless over an addiction is a choice, noone chooses to become an addict. As our Program Director, Geoff Thompson, often reminds our clients, children rarely tell their parents ”when I grow up, I want to be a drug addict.”

(*) Note: For more information, see Interview with Gene M. Heyman.

2) Powerlessness is a Lack of Willpower

Society often believes that, with a little bit of willpower, people can simply stop using drugs or alcohol or reduce their consumption to socially acceptable levels. This mistaken belief, however, is actually a failure to distinguish between the separate, progressive stages of compulsive use of chemicals or processes: abuse and addiction. As Carlton K. Erickson points out in his book, The Science of Addiction: From Neurobiology to Treatment, addiction is a failure to stop using in spite of negative consequences. Abusers of alcohol or drugs, most notably college students, will often stop excessive consumption when they are in a new environment where getting high or drunk is no longer encouraged, or when they experience negative consequences. For individuals with addictions, however, drinking or drug use will continue even after job loss, divorce, or illness.

Even for people who don’t struggle with addiction, however,  it is arguable whether simply trying harder is an effective method for attaining any worthy goal. Most who have tried to lose weight or have implored their children to improve their grades know that trying harder may work, but only temporarily. Without an effective strategy and implementation plan, willpower is not enough.

3) Powerlessness is the Same as Helplessness

Helplessness can be understood as the tendency for some addicted individuals to assign blame to external forces and avoid taking personal responsibility. So, when someone says “I am powerless to stop my addiction” they could be actually saying, for example, “my drinking wouldn’t be a problem if only my wife would get off my case.” This lack of accountability is typically obvious to everyone but the individual with the addiction, including those of us working in the field.

However, while it may be easy to spot helplessness in another person, determining the root cause of why someone is so incapable of taking action is far more challenging. For example, helplessness could be a response to childhood trauma, a phobia or depression. Taped recordings of AA Founder Bill Wilson suggest that he understood the link between helplessness and addiction. Following the sudden death of his childhood sweetheart, Bertha Banford, Bill Wilson concluded that “He knew now …. His need, his loving, didn’t matter a good goddam. His wanting, his hunger and desire, meant nothing to the terrible ongoing forces of creation and he would never forget this truth which he saw and accepted that night.” * Helplessness, as illustrated by Bill Wilson’s recollection, may not simply be a result of laziness but a reflexive survival mechanism in respsponse to painful past experience.

(*) Source: Thomsen, Robert (1975) Bill W.

4) Powerlessness is a Symptom of a Disease

The disease concept of addiction found an early advocate in the recovery movement with Dr. William Duncan Southworth, physician to AA founder Bill Wilson. By providing a physiological explanation for why alcoholics are powerless over their use of alcohol and through his close affiliation with Bill Wilson, Dr. Southworth helped shift the balance of power in addiction from organized religion to medicine. 

Dr. Southworth’s observation that alcoholism cycles between mental obsession and physical lack of control (or powerlessness) has stood the test of time. Defined this way, powerlessness is a common criterion used in the assessment of addiction. For example, Sunshine Coast Health Center recommends an addiction test, called the 3 Cs of Addiction: compulsion, control, and consequences. * What the 3 Cs test calls compulsion and control, Dr. Southworth calls, respectively, mental obsession and physical allergy. While the term ‘allergy’ may be arguable, alcoholics do appear to be physically powerless to stop drinking once the obsession to drink overpowers their decision not to drink.

(*) Note: see the Helplessness section above for information on the 3rd C - consequences.

5) Accepting Powerlessness is Critical to Lasting Recovery

First of all we had to quit playing God.
~ Alcoholics Anonymous, p. 62

This last example of powerlessness has been intentionally left to last since, unlike the first four definitions, this last definition will conclude this blog article on a hopeful note. Fortunately, many individuals have successfully come to terms with their addiction and have gone on to lead fulfilling lives in recovery. At Sunshine Coast Health Center, clients learn spiritual principles that often prove helpful as basic action guidelines in recovery. One spiritual principle, acceptance, seems particularly effective and is closely tied to the notion of powerlessness.

In his book, Not-God: A History of Alcoholics Anonymous, Ernest Kurtz suggests that “from the alcoholic’s acceptance of personal limitation [read powerlessness] - arises the beginning of healing and wholeness.” Furthermore, this message of “not-God” is, for Ernest Kurtz, an “affirmation of one’s connectedness with other alcoholics.” At Sunshine Coast Health Center, we wholly endorse the notion of connectedness, however, would extend it further to include family members, co-workers, and friends.

Conclusion

In the early days of Sunshine Coast Health Center, I will always remember how insistent one of our first clinicians was on the importance of making sure clients understand, at a gut level, Step One . As far as he was concerned, without a firm understanding of powerlessness, it is difficult, if not impossible, to properly work the remaining 11 Steps. However, I have learned over the years that words can often have multiple meanings and can trigger certain emotions depending on the perspective of the listener. By avoiding rigid absolutes, Sunshine Coast Health Center believes that it’s integrated approach allows clients to embrace multiple perspectives and, therefore, to appreciate the complexity that is inherent in any meaningful discussion on addiction.

By Daniel Jordan
General Manager
Sunshine Coast Health Center

In Part 1 of this article I highlighted the importance of designing a clinical brochure that is current, user-friendly, and comprehensive. Originally, I had planned to jump right in and explain our “integrated approach” to addiction treatment. However, as I was preparing for Part 2 I realized that exploring the complexity of residential addiction treatment is a necessary first step before attempting to explain our unique method of treatment.

Complexity #1: The Living Vs. Non-Living Universe

This may seem obvious but living entities are much more complex than inorganic objects. Neuroscientists point out that there are more synapses in the brain than stars in the galaxy and that the brain is the most complex device in the known universe. * The interesting part, however, is how we approach problems associated with living vs. non-living objects. In his book, Guide for the Perplexed, economist E.F. Schumacher argues that there are two types of problems in the world: (1) convergent and (2) divergent. 

Convergent problems are ones in which attempted solutions gradually focus on one solution or answer. Of primary importance is that convergent problems are those where that all tend to point to the non-living universe. Take, for example, the problem of manned flight. In the early days of aviation, there were many different contraptions that inventors hoped would become the first successful flying machine. Perhaps you have seen the old movie footage of planes with 4 sets of wings, or wings that would flap up and down, etc. Finally, after a lot of trial and error, Orville and Wilbur Wright made the world’s first flight in a powered, heavier-than-air machine on December 17, 1903 near Kitty Hawk, North Carolina. 100 years later, aeronautical engineers continue to improve on the Wright Brother’s original design, however, all manufacturers such as Boeing, Bombardier, or Airbus, build planes that follow remarkably similar design principles. The same is true for automobiles, cell phones, and portable computers.

Divergent problems are ones which we must find multiple solutions to a single problem and are typically found when we are dealing with living organisms, particularly human beings. For example, if you are trying to solve the problem of HIV/AIDS, handing out condoms or clean needles may be a start but it’s not going to completely solve the problem. Another agency may start a 24 hour help line and this may help as well. But these are just 2 of many possible solutions. The ongoing search for a cure to cancer, which is basically a living organism within a larger living organism (us), is another good example.  

(*) Source: Nuts, bolts of who we are, Princeton Weekly Bulletin, May 1, 2000.

Complexity #2: Chronic Conditions Vs. Acute Conditions

While many people may consider addiction a chronic condition *, the truth is that addiction has a lot more in common with diabetes, high blood pressure, and arthritis than it does with acute medical conditions such as a broken leg or appendicitis. This misconception is clearly evident whenever scientists claim to have found the gene responsible for alcoholism or pharmaceutical companies promote a new drug as the cure for addiction.

Even residential alcohol and drug treatment centers that should know better typically operate like hospital emergency wards, throwing everything they have at the client during primary treatment and leaving precious few resources for follow-up or relapse.

(*) Note: for more information on the chronic nature of addiction refer to William White’s articles on bhrm.org .

Complexity #3: Addiction Impacts All Life Domains

Unlike many medical conditions, addiction cannot be treated by localising the problem to a particular part of the body and then treating it. Addiction is a Biopsychosocial condition that impacts all life domains - biological, psychological, social and spiritual. For example, all may be well with a client while he is in the safe confines of residential treatment, however, what happens when he gets home where the same job, family, and old haunts await his return? Furthermore, most addictions impact negatively on the body (liver damaged by alcohol, tooth enamel destroyed by crystal meth or crack cocaine, etc.). Psychotherapy can be particularly challenging if a client is also suffering from cognitive impairment, or mental illness.

Not only does addiction require a diverse team of professionals to be involved in treatment, it means that often treatment often has to be applied concurrently, and that the discharge plan must include community resources that also embrace the Biopsychosocial nature of addiction.

Complexity #4: Addiction Defies Simple Definitions

The origins of addiction have been a source of lively debate for hundreds of years. Is it a learned behaviour or is it a disease? Is addiction a choice or is it a genetic predisposition? Is addiction caused by developmental factors or do some people have addictive personalities? Are addicts created by eating a diet deficient in certain nutrients? Or is addiction a response to feeling disconnected from the world?

As Ken Wilber in his book Integral Psychology states, “The great problem with psychology as it has historically unfolded is that, for the most part, different schools of psychology have often taken one of those aspects of the extraordinarily rich and multifaceted phenomenon of consciousness and announced that it is the only aspect worth studying (or even that it is the only aspect that actually exists).” Dr. David Burns, author of Feeling Good: The New Mood Therapy, calls it the “schools over tools” approach. This tendency towards over-simplification, commonly referred to as reductionism, is alive and well in the treatment of addiction. This is most unfortunate since addiction is a complex condition that impacts all aspects of health and lifestyle.  

Now combine debate among competing schools in psychology with the medical community and you begin to see why the matter of deciding on effective treatment for addiction is far from settled.

Complexity #5: Addiction Requires More Than Mere Abstinence

Even the goal of addiction treatment is a topic of lively debate. Some will reason that if only the addict will stop using his/her drug or process of choice (gambling, online porn, etc.) then the problems associated with addiction will go away. Unfortunately, just as health is more than the absence of disease, recovery requires a fundamental shift that impacts all life domains mentioned in Complexity #3.

At Sunshine Coast Health Center, we believe that abstinence is a by-product, not a goal of alcohol and drug rehabilitation. When an individual discovers his true calling and begins the process of living a life of purpose, we believe that ’external’ solutions and unhealthy attachments will be discarded in favour of being true to one’s self.

Complexity #6: Not Everyone With an Addiction is Motivated to Quit

Another point to ponder is that people with addictions actually need a reason to stop. Having something to lose (health, marriage, career) may work for a brief period of time but, long term, a fundamental shift or transformation is often required for abstinence to become permanent. Unlike most disorders or medical conditions, addiction produces a positive benefit for the individual such as dissociation (numbing out) or escaping from, what Narcotics Anonymous calls, the ”meaningless, monotonous, and boring” life of an addict.

Complexity #7: Primary Residential Treatment Vs. Outpatient Treatment

The last point to make on complexity is that residential addiction treatment, is more than just counselling with room and board thrown in for good measure. Social skills associated with the give and take of living 24/7 with a peer group is an issue for residential treatment while the same can’t be said for outpatient.

Furthermore, group therapy, commonplace in residential treatment, is rarely provided in most outpatient settings. Group therapy is, by nature, a dynamic process that can have remarkable therapeutic effect in the hands of a skilled psychotherapist.

Complexity #8: Addiction is More Than Just Drugs and Alcohol

Cross-addiction (having more than one addiction) is a common occurence for individuals who struggle with drugs or alcohol. Sunshine Coast recognizes this tendency and is redesigning its program to expand the definition of addiction to include process addictions such as gambling, gaming, sex, even eating disorders.

Conclusion

Addiction is a complex condition that requires an equally complex approach to treatment. Sunshine Coast Health Center recognizes these challenges and has been continually finding new ways to enhance program effectiveness. in Part 3 of The Challenge of Writing a Clinical Brochure, I will examine how other individuals and groups are integrating their approach to address complex problems.

By Daniel Jordan
General Manager
Sunshine Coast Health Center

If there has been one thing that has been a constant at Sunshine Coast Health Center, it’s change. Changes at our residential addiction treatment center tend to occur under four broad categories: (1) program, (2) staffing, (3) services, and (4) facility. Since one of my responsibilities is marketing, it dawned on me that the corporate brochure that we created in the spring of 2007 was due for an overhaul. So, back in March, a new pamphlet was produced that showed our newly-expanded drug rehab center (new building, new indoor exercise pool, expanded fitness center, landscaping, etc.) and enhanced services (mental health services, on-site fitness, off-site recreation). However, after inserting all the new photos that highlighted our facility and campus, there really wasn’t much space left to detail how the clinical program has changed.

So, since the spring, we have been working on creating a brochure that provides additional information that is primarily clinical in nature. Having committed to this project, however, I soon realized that creating a clinical brochure that is comprehensive, user-friendly, and current is a big job!

The Challenge of Being User-Friendly, Current, and Comprehensive

In many ways, this reminds me of the work leading up to our publishing of the 1st edition of the British Columbia Alcohol & Drug Services Directory last November. It was the first time in 8 years that anyone had published anything similar to a directory of this nature (the last Kaiser Directory was published in 2001). I had found a number of BC addiction directories but all of them had one problem or the other. For example, either the information was outdated (again, the Kaiser Directory, many addiction directories found online), or was not presented in a user-friendly fashion (the Red Book in BC has quite a few listings but suffers from excessive categories and bulk), or was not comprehensive (no addiction listings felt that private practice therapists that worked with addicts or 12-Step meetings were worth listing). So, the challenge then became to integrate all of the available information into a publication that was better than the sum of its parts. Based on feedback we have had from many health professionals across BC, it seems as though we have succeeded in our objective. But while I thought the directory was a challenge, it seems as though creating a clinical brochure is a much more difficult task. After five months of internet research and countless visits to libraries, and used bookstores, I figure it’s time to start putting it all together, and what better place to start than our blog?

Challenge #1: Being User-Friendly

When it comes to having a user-friendly clinical brochure a logical presentation of content is necessary. However, a clinical program can’t be arranged in a simple, linear fashion like a novel or historical account. Instead, a framework needs to be designed so that all of the pieces are arranged in such a way that makes sense.

Finding material to aid in the development of a framework has been interesting, to say the least. Philosopher Ken Wilber has been instrumental in creating integral models that embrace the human condition from a subjective (”I” and “We”), objective (organism and environment), and structural (mind, body, soul, spirit) perspective. Ervin Laszlo, a pioneer in systems thinking; Roger Martin, author of The Opposable Mind; and economist E.F. Schumacher have all written on designing models that help explain complex systems. However, incorporating a system so that the system itself does not become the focus of the brochure is going to test the limits of being user-friendly.

Another aspect of being user-friendly is avoiding jargon that is so prevalent in health sciences and philosophy. Relapse Prevention expert Terence T. Gorski once pointed out to me that it’s often a question of languaging: communication can break down when we fail to understand that different words are used to represent the same thing. For example, one clinician may use the term resistance while another uses the term denial to represent the inability or unwillingness of a client to make healthy changes. So, a user-friendly clinical brochure must be presented in a way that doesn’t just assume familiarity with terminology commonly associated with alcohol and drug treatment.

Challenge #2: Being Current

Sunshine Coast Health Center is an evolving entity and that is by design. However, when creating a clinical brochure, information about staffing, programs, and services must be presented in a way that can embrace these changes without becoming outdated. For example, we may decide to change out an adjunct therapy (massage, relaxation, ozone, etc.) based on published research, client feedback, or staff turnover. However, such changes to the clinical program at the programming level does not automatically mean that the program, for example, no longer addresses the physical aspects of addiction. 

Highlighting qualifications of staff must also be presented in general terms (such as all counsellors requiring a minimum of a master’s degree) rather than focusing on particular techniques (Cognitive-Behavioral Therapy, Motivational Interviewing, etc.) that individual counsellors possess.

Challenge #3: Being Comprehensive

Addiction is a complex condition that defies a simple solution. While it’s somewhat straightforward to simply provide a list of programs and services, explaining why clinical elements have been included and how all of the clinical elements work together (our philosophy) is another story. A drug treatment program is far more than just it’s ‘bits and pieces’. Furthermore, a good clinical brochure should be able to demonstrate that its programming is supported by evidence-based research if it expects to be supported by the health professional community it needs to remain viable. And then there’s the addiction treatment-specific issues that always come up such as ‘how do you deal with disruptive clients?’, or ‘what happens when a client has a relapse?’. Answers to these policy questions often reveals a lot about a program’s philosophy.

Conclusion

Explaining how our program has integrated all of its clinical elements in a user-friendly, current, and comprehensive fashion is proving to be more challenging than originally anticipated. In Part II of this series, I will expand on why our program, based on our unique integrated approach to addiction treatment, is particularly challenging to summarize in a clinical brochure.

By Geoff Thompson, MA, CCC – Program Director

One of the key features of the new program at Sunshine Coast Health Center is beginning the process of living a personally meaningful life—finding a way to overcome those nagging feeling of emptiness, boredom, loneliness that are at the core of addiction.

One more example of this understanding of addiction and recovery is Gabor Mate’s book, In the Realm of Hungry Ghosts, provides a description of addiction. Although he talks about biological predispositions and effects of the drugs (he’s a medical doctor), he refers often to the addict’s “void” or “emptiness” as the motivation for drug use.

Despite the recent flurry of writing on this approach, it’s not a new idea in the addiction field. The most famous attempt to help addicts fill that nagging emptiness is, of course, the 12-step program. Bill Wilson’s idea was that if the alcoholic could truly accept the presence of a benevolent higher power, then he would come to understand that his life was meaningful and worthwhile. The Big Book refers to this at one point as “God-consciousness.”

Most experts, like Gabor Mate, talk about connecting with some higher power as the means of achieving a meaningful life. But a big problem that some people encounter is the assumption that there exists a benevolent higher power (HP), one that has your best interests at heart. Someone pursing the steps, for instance, who doesn’t believe in this HP, will struggle mightily. Many AA and NA members argue that those who don’t believe in this benevolent higher power are simply ignorant or naïve; they have to “fake it ‘till you make it.”

But that plan might not work too well. Research psychologists at the University of New Mexico have found that the tactic of “fake it ‘till you make it” doesn’t work for the majority of those in early recovery.

If you are struggling with the dilemma of not believing a benevolent higher power and discovering that trying to fake it doesn’t work, are you doomed to relapse or the miserable life of a dry drunk? Thankfully, no.

The first thing to appreciate is that some of the finest thinkers in the past 100+ years have argued that the force that governs the world has no interest in human needs or desires. Geniuses such as Friedrich Nietzsche, Jean-Paul Sartre, and Eugene O’Neill did believe in such a higher power—they said that the higher power could care less about human needs or wants. Their higher power was simply some force that exists for its own sake. Think of gravity. It simply is. Gravity doesn’t care about you or anything else. For example, an avalanche or the stairs that you trip on don’t care one way or the other if you have kids or parents or provide paycheques to employees. Obviously, it would be crazy to put your faith in a higher power that does not care about you.

In our scientific and technological society, the idea of a benevolent higher power has little appeal for many. But if you don’t believe in a benevolent higher power, you aren’t doomed. In fact, each of the geniuses mentioned above gave us his own particular answer to filling the void, to finding some way of living that would make someone feel his life was worthwhile and important.

In this blog article we’ll take a look at four of their ideas: don’t be a sheep, practice grace under pressure, do the next right thing, and connect with others.

Don’t be a sheep

The great thinker, Friedrich Nietzsche, talked of the importance of sticking to your convictions (your values and beliefs), as a way to live a meaningful life. He said that the easy way out of life’s struggles was to follow the masses and do what others do. In psychology this has been called the “herd mentality.” The great addict-writer, Eugene O’Neill, called these people the “spiritual middle class…how petty their dreams must have been.”

People in recovery who are part of the herd are willing to give up who they are in order to be part of a group. Their need to belong is so great that they are willing to sacrifice themselves.

We have had phone calls from alumni who tell us they are struggling. When we unpack their struggles, we often find that they have become sheep. One fellow said that the pressure from his family was so great to attend meetings that he felt he no longer went to AA to find recovery; he was just going there to keep his family off his back. Another alumnus told us that he was simply going through the motions of recovery because he hoped that “something” would happen. He did this because it kept family was happy; in fact, everyone was happy except him.

Recovery demands filling the void. If the tactics you are using are not giving you a sense of vitality and energy, then this is a big red flag that you’d better switch tactics. It is likely that you aren’t paying attention to what you believe and value; you’re simply following the herd. This lack of vitality is a relatively common complaint from those alumni who just attend 12-step meetings. But, remember, that the steps are the key to the program, not meetings, and the steps demand of you that you find your own personal way through them: “To thine own self be true.”

“Grace under pressure”

This phrase is from the alcoholic writer, Ernest Hemingway, who believed that meaning came from facing a struggle heroically, without crashing and burning, without whining and whimpering.

And not just Hemingway. Eugene O’Neill and Friedrich Nietzsche, for example, agreed that the heroic person faced life bravely even knowing in the end he was doomed. It was this heroic stance that made the individual’s life important and worthwhile.

To understand what they were talking about, think of just about any Hollywood movie. The hero faces great odds to overcome a challenge: James Bond has to battle the evil genius, the small high school basketball player has to make the team, a group of men plan to rob the most secure casinos in Vegas, Sylvester Stallone has to face his own fears to rescue a friend in the mountains, and so on.

Of course, in Hollywood movies, the hero usually wins in the end, but winning is not a requirement. Will Smith in Seven Pounds takes his own life in the end. Edward Norton in 25th Hour goes to jail. Yet, we still admire them. 

These movies are popular because we admire the person who overcomes great odds. It is the struggle that is important. How popular would any of these movies be if the first time the hero runs up against a challenge, he throws up his hands and says, “F-it…I’m gonna get drunk.”

“Do the next right thing”

Writer Anne Lamott wrote, “I took a long, deep breath and wondered as usual, where to start. You start where you are, is the secret of life. You do the next right thing you can see. Then the next.” FYI: Lamott has written on alcoholism.

A friend of mine who has 27 years of sobriety takes these words to heart. In his experience, doing the next right thing has remarkable power to help him feel that life is meaningful and worthwhile. He worked at another facility, and I remember him giving money to a former client for cab fare. Sensing that the former client might squander the money on drugs, he said to the fellow, “Do the next right thing.” I don’t know if the fellow actually got a cab, which was the next right thing.

In recovery, doing the next right thing can look any number of ways. If you get a craving for booze, the next right thing is to not take a drink. If a family member gets angry at you, the next right thing is to stay calm. If you are in a tricky position where you know you can get out of it by lying, the next right thing may be to tell the truth. If you feel depressed, the next right thing may be to force yourself off the couch and go to a meeting. If someone is rude to you, the next right thing is to think that they may have had a really bad day. And so on.

Connect with others

We’ve talked about this one before, but it’s worth repeating. One of the keys to recovery is to connect with others at a deep human level. In active addiction we connected at a superficial level.

Here’s some research that highlights the importance of connection for recovery. An interesting, and little known, fact is that clergy and pastors have an addiction rate higher than the national average. Researchers first thought that this may be because they lost their faith in God. As it turns out, this is not the case. So, here we have clergy and pastors who have a firm belief in a benevolent higher power, and yet their addiction rate is high. How do we explain this?

Here’s one thing we’ve discovered: One of the biggest problems for clergy and pastors is that they don’t really connect that well with others. It’s never a level playing field. They are the ones people turn to when in trouble. They are the ones people turn to for answers.

And clergy and pastors always have to be conscious of the image they present to others, since they are considered role models. But what happens if a pastor has a big argument with his wife or doesn’t feel well or suffers from depression/anxiety? They still have to be role models, still have to present a certain image in public, still have to be ‘on their game’.

Another example is the novel/movie Leaving Las Vegas. Ben and Sera, the main characters, could easily dismiss each other: Ben is an alcoholic and Sera is a prostitute. They could reject the other; however, they learn to care for the other as a suffering human being. Leaving Las Vegas is a plea for us to care for each other, even those whom society dismisses as unlovable.

By Geoff Thompson, MA, CCC
Program Director, Sunshine Coast Health Center

Movies provide good lessons on what it means to be an addict and what it means to recover. Thoughtful movies, that is, not the sanitized and simplistic versions of recovery promoted in, for example, 28 Days with Sandra Bullock. This month on the alumni online program we’ll look at four thoughtful movies: Leaving Las Vegas, Under the Volcano, Hurlyburly, and Barfly.

These four movies don’t bother with superficial aspects of addiction or recovery. None of these movies is interested in what ‘triggers’ the addicted character’s cravings or their ‘maladaptive coping skills’. None of these movies labels addiction as a ‘disease’ or some sort of escape from life.

Rather, they provide us with a deep psychological understanding of what it means to be addicted. Like so many thoughtful works on addiction, they see the addict at a human level. The main characters are simply individuals who are struggling to make sense of their lives.

If you were at Sunshine Coast Health Center (”Sunshine Coast”) under our new therapy, you heard about the great psychologist, Viktor Frankl. These movies confirm Frankl’s explanation of addiction: “[A]lcoholism…is not understandable unless we understand the existential vacuum underlying [it].” The term, “existential vacuum,” means that a person struggles to find any satisfying meaning or purpose in life. Because of this, life seems boring and dull.

If you were at Sunshine Coast under the old therapy, the 12-step program agrees with Frankl’s idea. Narcotics Anonymous’ version is that the addict’s life is “meaningless, monotonous and boring.” Alcoholics Anonymous calls this feeling the “God-shaped hole” in life. Bill Wilson believed, of course, that this existential vacuum was why alcoholics drank, though he didn’t use Frankl’s term. The alcoholic was trying to fill the vacuum with booze. Remember that Bill W. said at the Shrine Auditorium in LA in 1943 that the alcoholic is the fellow “who is ‘trying to get his religion out of a bottle’, when what he really wants is unity within himself, unity with God….”

So many people in early recovery do not really appreciate how profound this idea is. They truly believe that if they quit the drug and get over their anger, depression, or whatever, then they will lead the good life. And they seem very surprised when they realize that this plan isn’t working too well for them.

But Bill W. and Frankl would not be surprised. They understood addiction at a human level. So, we’ll examine our movies and see if we can find in them any nuggets to help you fill that ‘God-shaped hole’ or that existential vacuum. 

Movie One—Leaving Las Vegas

Nicholas Cage (as Ben) and Elizabeth Shue (as Sera) do a wonderful job bringing to life John O’Brien’s novel, Leaving Las Vegas. This movie won 17 major awards and was nominated for 25 others. It’s a sad movie, but not depressing. And the great thing is that it doesn’t have all those stereotypical comments and scenes that we find in the sappy Hollywood versions of addiction.

As a sideline note, the late film critic, Roger Ebert, wrote his review of the movie on November 10, 1995, and said: “The practical details are not quite realistic—it would be hard to drink as much as Ben drinks and remain conscious….” Ha! Ebert obviously didn’t hang out with alcoholics.

One very interesting point about Leaving Las Vegas is that we really know nothing about the main characters. We don’t know about Ben’s ‘issues’; we don’t know why he’s drinking. All we know is that he is drinking himself to death. When this is pointed out to Ben, he turns it around, saying that his dying allows him to drink.

Ben knows exactly what he is doing. The movie is a plea for us to care for each other. It is a love story, and Ben and Sera care for each other even if the rest of society dismisses them. Ben knows that he could find happiness with Sera. But something makes him take another drink. This isn’t because he has a ‘disease’ or poor coping skills. Ben is struggling to find some sort of answer to suffering.

Ben’s real problem seems to be that he isn’t willing to fight for himself. Frankl said that happiness demands the “defiant human spirit,” the willingness to fight for your life. Ben recognizes his own suffering, he recognizes that most people live superficial lives, he recognizes that what advertisers call the ‘good life’ is all nonsense. But he is unwilling to take a heroic stand. Instead, he clings to his belief that only through drunkenness can he be free to be himself.

You should know that O’Brien committed suicide two weeks after signing the rights to make his book into a movie. His father said Leaving Las Vegas was his suicide note.

Movie Two — Under the Volcano

This movie with Albert Finney is based on Malcolm Lowry’s famous novel, Under the Volcano. There’s a BC link to the story. Lowry wrote the novel in Deep Cove, where he sobered up. And, interestingly, Nicholas Cage said that he studied this film as a role model for his character, Ben, in the movie Leaving Las Vegas.

Under the Volcano is one day in the life of Geoffrey Firmin, an alcoholic British consular officer in Mexico. We spend the day with him as he tries desperately to stay drunk, despite pleas from his doctor, friends, brother, and wife. 

The setting is the Festival of the Dead, which foreshadows Firmin’s fate as well as his life. He’s not very happy. He has lost his wife to the booze, his brother thinks he is crazy, and his doctor repeatedly warns him that an alcoholic death is not far off. Firmin struggles desperately to figure out a future where he can find peace of mind.

The year is 1939, when the world was plunging toward world war. The Western world seemed to have gone insane—another world war, one generation away from ‘the war to end all wars’. Safe in the obscurity of a small town in the south of Mexico, Firmin has tried to run away from the craziness only to find that he, too, is no better off.

Movie Three — Hurlyburly

Originally a famous play by David Rabe, Hurlyburly brings together several small players in the Hollywood film business in 1980s (the film version was updated to the 1990s). All the characters exist in an ‘existential vacuum’—there is a ‘God-shaped hole’ in their lives.

Eddie is the main character. He’s a drug fiend and is soon to hit bottom. The other male characters are in little better shape. There aren’t any real connections between the characters, which they openly admit. And women are useful mainly as sex objects and as presents to give to other male friends.

Eddie talks a lot, desperate to find some meaning in his empty life. A typical example is this dialogue between Eddie and Mickey:

Mickey (Kevin Spacey): You don’t know what you’re saying. You don’t.
Eddie (Sean Penn): I do.
Mickey: No. I know you think you know what you’re saying, but you’re not saying it.
Eddie: No, I know what I’m saying. I don’t know what I mean, but I know what I’m saying. Is that what you mean?
Mickey: Yeah.
Eddie: Right. But it’s not like anybody knows what anything means, right? It’s not like anybody knows that. So at least I know I don’t know what I mean, which is better than most people. They probably think they know what they mean, not just what they think they mean.

This little exchange highlights Eddie’s dilemma of trying to figure out how to live a meaningful life. People only think they have meaningful lives, according to Eddie, but they’re just fooling themselves.

In the film, drugs (and sex) are distractions from coming to terms with his “meaningless, monotonous and boring” life, as Narcotics Anonymous would judge Eddie’s existence.

Movie Four — Barfly

Barfly is a novel written by the addict-writer Charles Bukowski. He based it more or less on his own life. Bukowski became famous writing lots of poetry and short stories and novels about the addicted ‘down-and-outers’. The film version of Barfly (with Mickey Rourke) has become a cult classic about the American subculture.

The central setting of the film is a bar, where Henry (Rourke) is at home, drunk as usual and getting into fights as usual, particularly with the bartender. But Henry also has a talent for writing poetry. A healthy-minded socialite appreciates his literary genius and convinces him to sober up and get serious about his writing. He agrees, and she organizes his life for him, including providing him with a place to stay and making sure he is introduced to the movers and shakers in the artistic world.

But Henry soon realizes that he has given up control of his life to her. Eventually, he returns to the bar and his old lifestyle.

A typical healthy-minded person would likely be perplexed why an addict would choose to be an addict, especially after tasting the ‘good’ life. Henry has a new wardrobe, is well fed, is making new healthy friends. So why return to drunkenness and fighting the bartender?

The problem for Henry is that, clean and sober in his new clothes and going to formal parties, he realizes that he has lost control of his own life. If a person is to be happy, says the movie, he must feel in charge of his life. For Henry, the only place where this is possible is in the bar, drunk and fighting. 

Obviously, coming to some place like Sunshine Coast is not even in Henry’s mind. But if he did come to Sunshine Coast, he would hear us tell him: “You are the author of your life.” That would make sense to Henry.

Bill Wilson, the legendary co-founder of Alcoholics Anonymous, would find the program at Sunshine Coast Health Center (”Sunshine Coast”) very much to his liking. Sunshine Coast interprets addiction and recovery in the same spirit as Wilson did, the difference being that Sunshine Coast’s program is based on scientific research.

Key points

Influences on Bill Wilson

In 1961, two decades after the birth of AA, Bill Wilson wrote a thank-you letter to Carl Jung for his influence on AA. In the letter, Wilson mentioned the other three influences on the development of AA: William James, William Silkworth, and Samuel Shoemaker (from the Oxford Group).

We know from Bill Wilson’s psychoanalyst, Harry Tiebout, that Wilson read Jung’s work. And we know from the letter that Jung sent to Wilson that the Swiss doctor confirmed Wilson’s interpretation of addiction and recovery, arguing that alcoholism was a spiritual condition that demanded a spiritual solution. In his letter to Wilson, Jung wrote that the alcoholic’s “craving for alcohol was equivalent on a low level of the spiritual thirst for our being for wholeness, expressed in Mediaeval language: the union with God.” He went on to tell Wilson that “You see, alcohol in Latin is “spiritus” and you use the same word for the highest religious experience as well as the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.”

Jung argued if someone suffered from an “unrecognized spiritual need,” then alcoholism was one response. Only spirituality (some conversion experience) was powerful enough to overcome the spirits provided by alcohol.

Bill Wilson learned about William James when a friend gave him a copy of The Varieties of Religious Experience while Wilson was detoxifying in Towns Hospital. In the book, James wrote that getting high on alcohol or nitrous oxide was a mystical experience, one form of religious experience.

William Silkworth had been Wilson’s personal physician. Silkworth had attempted to provide a biological basis for the common observation that alcoholics reacted qualitatively differently to alcohol than non-alcoholics, though Wilson did not share Silkworth’s specific interpretation that the alcoholics had an “allergy.” But what helped Wilson was knowing that there must be a biological basis to alcoholism, that it was not a matter of character weakness or sin.

Strangely, the ‘disease’ concept became linked to AA in the popular mind, though it was never really a fundamental part of AA. Wilson had never taken a medical course and knew nothing of Koch’s postulates that inform our current pathology models. He used the term as a metaphor and emphasized that “Alcoholism is a disease that only a spiritual experience can conquer.” If we take Wilson’s “disease” literally, it is the strangest ‘disease’ in the history of pathology, since no medicine can help the sufferer. That AA became linked to the disease model was likely the result of the public health professionals awarding prizes to AA, promoting the idea that AA’s influence was to interpret addiction as a “disease.” This interpretation was clearly antithetical to Wilson’s idea, which promoted addiction as a “spiritual” condition.

Samuel Shoemaker ran the local Oxford Groups that had helped Wilson and others in their early recovery and provided a rough version of the 12-step strategy: admit there is a problem, confess character defects, make amends for harm, and help others. Despite this early influence and Wilson’s recognition of it, he pulled the early AA out of the Oxford Group in less than a year because he believed that their views were too rigid.

SCHC and Wilson’s Interpretation of Addiction and Recovery

Sunshine Coast is very much in line with the 12-step interpretation of addiction and recovery, the difference is that we base our interpretation on research evidence and psychological theory.

Viktor Frankl had said that “Alcoholism is not understandable unless we recognize the existential vacuum underlying it.” Frankl believed that human beings had an inherent need to make sense of their lives at a deep level. When this need was persistently frustrated, then alcoholism could be one result. Research has confirmed that quality of recovery improves with an increase in personal meaning. Andersen & Berg (2001) conducted longitudinal studies and concluded that meaningful living was linked directly with abstinence, a conclusion that William White (2004) also found. Frankl’s therapy, known as logotherapy, has produced several treatments for addiction (Crumbaugh, 1980; Langle, 2005; Somov, 2007). Paul Wong, who developed the form of therapy that we use at Sunshine Coast, also has applied a form of Frankl’s work to help addicts recovery (2005).

Based on the influences of James, Jung, and Shoemaker, Wilson always maintained that alcoholism was a response to living the personally meaningless life. In 1943, at the Shrine Auditorium in LA, he described the alcoholic as the fellow “who was trying to get his religion out of a bottle, when what he really wanted was unity within himself, unity with God.” According to Wilson, the pursuit of drunkenness was the pursuit of a connection with oneself and a connection with some force that would provide him with a belief that he was ‘part of’, that he belonged in the world around him.

And the addict was disconnected even from himself. The “defects of character” and “wrongs” were symptomatic of alcoholism and maintained the alcoholic’s disconnection from the world: jealousy, anger, grandiosity, impatience, and so on. The Big Book uses the example of jealousy to show that what the jealous person really wants is to love and be loved; jealousy was merely the alcoholic’s tactic to protect himself from losing his lover. So, the alcoholic’s defects were those that prevented his being authentically true to himself.

The stories of AA members in the Big Book, which take up two-thirds of the book, are a catalogue of suffering that arises from this disconnection from the self and the world—and ultimately from any higher power that could provide some overarching meaning—as expressed through the ‘defects of character’.

If the alcoholic’s problem was essentially a separation from his true self, a separation from others, and a chronic feeling of emptiness, of something missing, then the solution must address this disconnection. The AA program is designed specifically to help the AA member reconnect with his authentic self, reconnect with others, and reconnect with a Higher Power. Silkworth contributed “The Doctor’s Opinion” to the Big Book, where he described the goal of recovery as “an entire psychic change.” Step 12 describes this as “a spiritual awakening.”

According to AA, this entire psychic change could be relatively quick, but more often was of the “educational variety,” a phrase borrowed from William James. This change specifically grew out of spiritual experiences, or what is called at one point in the Big Book, the development of “God-consciousness.”

Sunshine Coast also has as one its main clinical goals the beginning of the process of “transformational change,” a phrase from White (2004), though others have called this a “quantum change” (Miller & C’de Baca, 1994). Like Wilson, these psychologists concluded that abstinence may be the byproduct of transformational change, not the first step in recovery or the prerequisite to recovery.

Transformational change, for both Wilson and the psychologists, meant that a person began living a life that was true to their authentic self. For Wilson, comfort arose from a faith in some transcendent power, and thus the alcoholic had no need to distort or hide experience. For the psychologists, it was a matter of choosing a life that was true to the self, thus changing fragmented personality into a congruent one, aggressiveness into assertiveness, and conventionality into authentic living.

At Sunshine Coast, transformational change is essentially this process. We use narrative therapy to help clients understand how they have interpreted their lives in a way that is not working out for them. Their narrative also maintains they’re disconnection from self, others, and from anything that would provide some overarching meaning in their lives.

Wilson’s Interpretation of AA as a Personal Journey

The steps are deliberately vague. Wilson believed that each person had to find his or her own way through them. Recovery was a personal matter and no recipe could be provided. The most obvious example of this is Step 2: “Came to believe that a power greater than ourselves could restore us to sanity.” This is the end result, but the key to this step is to figure out ‘how’ to come to believe. AA provided a book, Came to Believe, to help members. This book is 100 stories of how 100 different members found 100 different ways to come to believe. Wilson’s strategy was to provide a framework, not a recipe for recovery. He believed that only a journey that was personally meaningful to the individual would be successful.

Wilson and Professional Help

It is an interesting phenomenon that many AA disciples believe that Bill Wilson was divinely inspired. This may be an artifact of the conservative Christian influence on AA, in that conservative Christianity pervaded American society at the time and was, for example, the driving force behind prohibition legislation in the US (as was the women’s rights movement). But it is logically impossible to understand this belief given that Wilson had specifically mentioned the influences on AA in his letter to Jung.

And Wilson, himself, would have been disturbed that others thought that he somehow had a direct line to God when they did not. He had repeatedly declared in public that “Nobody can cause more grief than a power-driven guy who thinks he has got it straight from God. These people cause [the world] more trouble than the harlots and drunkards.” And he often said that “AA is a terribly imperfect society because it is make up of terribly imperfect people.” Ernest Kurtz provides a more down-to-earth explanation that Wilson and AA had resurrected a form of spirituality that celebrated human imperfection as not merely a fact but as the stepping stone to a connection with God.

What Sunshine Coast does in it’s program that Bill Wilson would like

1. Our family program introduces the 12-step program to families.
2. Clients attend AA/NA weekly. And an on-site meeting with local AA/NA members helps clients become comfortable in a meeting environment (although, because we invite only alumni and friends of SCHC, this meeting cannot be sanctioned by AA/NA).
3. Each week we provide a workshop on one of AA/NA’s spiritual principles, which also have a basis in the scientific study of positive psychology. The steps emphasize that recover comes from practicing these principles.
4. Each week we provide a workshop on the 12-step program as interpreted by scholars such as Ken Hart and Ernest Kurtz. This workshop highlights the origins of AA as well as practical matters of membership. It also highlights the influence of 12-step based treatment on AA, so that clients are not confused about certain things they hear at meetings that contradict other parts of the program. As one example, a long-term AA member may share at a meeting about how miserable their life is, when the 12-step program itself emphasizes “what it was like, what happened, and what it is like now,” because Bill Wilson understood the importance of providing a message of “experience, strength, and hope.”
5. The overarching theme at Sunshine Coast, which informs every component, is that recovery means reconnecting with self, others, and with a Higher Power, which is how Bill Wilson defined “spirituality.”
6. Workshops are usually conducted offering a psychology point of view matched with the 12-step point of view. For example, clients learn that Viktor Frankl’s recipe for happiness is to ask oneself “What does life demand of me?” is matched with the 12-step saying “Live life on life’s terms.”

 Twelve-step principles are also infused throughout the program:

1.  Staff attitudes are based on empathy and unconditional positive regard, just as AA emphasizes “principles before personalities.” They do not succumb to power struggles with clients; they do not tell clients what to believe.
2. Staff practice the spiritual principles, under the 12-step principle of “attraction, not promotion.”
3. Each client is encouraged to find his own way through recovery.

Conclusion

The 12 Steps of Alcoholics Anonymous has become synonymous with addiction treatment even though it was never intended to be professionalized into therapy. However, Sunshine Coast recognizes the importance of spirituality as an important ingredient in recovery and has included psychoeducation group discussion that focuses on the evidence-based aspects of the Big Book. Furthermore, since 12 Step groups are often the only source of recovery (particularly in small communities) for many individuals in North America, Sunshine Coast believes it is important that clients have a better understanding of some of the misconceptions that have fueled the controversy surrounding the 12 Steps.

Readers with questions about the philosophy of Sunshine Coast Health Center are invited to contact us directly at info@schc.ca

References

Andersen, S., & Berg, J.E. (2001). The use of a sense of coherence test to predict drop-out and mortality after residential treatment of substance abuse. Addiction Research & Theory 9(3), 239-251.

Crumbaugh, J.C., Wood, W.M., & Wood, C.W. (1980). Logotherapy: New help for problem drinkers. Chicago, IL: Nelson Hall.

Langle, A. (February 4-5, 2005). Addiction and the search for meaning. Two-day workshop presented at Trinity Western University, Langley, BC.
 
Miller, W.R., & C’de Baca, J. (1994). Quantum change: Toward a psychology of transformation, in T.F. Heatherton, & J.L. Weinberger (Eds.). Can Personality Change? (pp. 253-280). Washington, DC: American Psychological Association.
 
Somov, P.G. (2007). Meaning of life group: Group application of logotherapy for substance use treatment. Journal for Specialists in Group Work 32 (4), 316-345.
 
White, W.L. (2004) Transformational change: A historical review. Journal of Clinical Psychology 60(5), 461-70.
 
Wong, P.T.P. (October 5, 2005). Meaning-centered approach to addiction prevention, treatment and recovery. Workshop presented at Vancouver Community and Family Services, Vancouver, BC.