Canada Drug Rehab

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.

Watch Hollywood movies, such as 28 Days with Sandra Bullock, or television talk shows, such as Oprah, and you might get the idea that the typical treatment program is well designed and effective.

You might think this until you read William Miller, one of the acknowledged gurus in the field. Miller commented in 2007: “What is actually being done in most addiction treatment programs? The truth is that no one really knows, including the administrators and supervisors of those programs.”

How this happened is a fascinating story. In 1949 several recovering alcoholics and community-spirited volunteers opened Hazelden, a treatment center for alcoholics in Minnesota. They really had no idea what they were doing. The healthcare profession was at a loss with what to do with ‘hopeless’ inebriates. But the Hazelden founders did know about Bill Wilson, who created a self-help program called the twelve steps. Since Wilson was having more success than the professionals, they gratefully borrowed the steps and tacked on medical, psychological, and religious components.

By the 1960s, Hazelden’s program would be known as the Minnesota Model, by far the most popular treatment for addiction. Various centers modified the model, and these are now known as “12-step based” treatment. Our best estimates from the US tell us that about 95 percent of all treatment facilities are 12-step based.

A typical counsellor was a recovering addict who attended a 12-step based treatment program, followed by membership in Alcoholics Anonymous or Narcotics Anonymous.

With so many facilities offering 12-step based treatment, rather odd ideas about addiction and recovery became the paradigm. For example, treatment providers relied heavily on the ideas of psychiatrist Harry Tiebout. Tiebout was trained in Sigmund Freud’s psychoanalysis, described himself as a “side-line observer” of Alcoholics Anonymous, and even treated Bill Wilson. Based on this experience, he declared in 1944 that the “so-called typical alcoholic is a narcissistic egocentric core, dominated by feelings of omnipotence, intent on maintaining at all costs its inner integrity.” Tiebout’s ideas were so influential that even Alcoholics Anonymous published his work.

Although modern psychology has advanced tremendously since Freud, disciples of 12-step based treatments continue to stick with this early psychology. Even today, they design programs around concepts that even neo-Freudian psychology has long since dismissed.

Second, counsellors generally believed there was no need to keep up on theory and research. Few counsellors had university degrees, much less training in statistical analysis or research methods. Many had no training whatsoever. Pouring through research articles was neither a priority nor even encouraged. Although the situation today is changing, it remains much the same 60 years later.

Third, the counseling style was confrontational because the counsellor had to break through the addict’s ‘denial’ (one of Freud’s ideas). The addict left to his own devices was a disaster, because, as Tiebout had said, the alcoholic would maintain his egocentric integrity at all costs. This form of counseling continues today, despite the overwhelming evidence that confrontation does not work and can harm clients.

Fourth, if clients did not do exactly what their counsellors told them to do, they were inevitably discharged. Such clients were judged “not ready” for treatment and had to do “more research” before they were serious. Studies of current programs continue to show discharge rates as high as 80 percent, with an average of 40 percent.

Fifth, counsellors developed the idea that only someone who had personal experience with addiction could counsel addicts. The continuing pervasiveness of this idea today is remarkable, considering that every study done on this issue has shown that it is simply not true.

One of the strangest of ideas was that almost no one thought it important to study how successful their treatment was. Staggering sums were being spent on treatment, and no one had a clue if it even worked. As we now know, it wasn’t very good. Even today, most counsellors and program supervisors have never bothered to study what they do and how successful they are. This explains, of course, Miller’s observation that “no one really knows what is actually being done in most treatment programs.”

Despite this bleak picture, there is much hope. Research-based treatments, such as Alan Marlatt’s relapse prevention programs and William Miller’s motivational therapy, are showing better results than we’ve ever seen. Faced with overwhelming pressure to update its program, even Hazelden has distanced itself from the past and begun publishing quality research. 

This is all good news. Still, it is one more strange thing about treatment that most counselors and their supervisors refuse to take a long, hard look at what they are doing.

About the Author

Geoff Thompson, MA, is the Program Director at Sunshine Coast Health Center, a private addiction treatment facility for adult men. His book, A Long Night’s Journey into Day, explores Eugene O’Neill’s life to uncover the truth of addiction and recovery.

By Geoff Thompson, M.A., CCC

People in recovery seem to talk constantly about the importance of a support group. One of the saddest things we hear from some in early recovery is that they think having a support group is a sign of personal weakness—‘I should be able to do this on my own.’ But it has nothing to do with weakness. In fact, being around supportive people is a natural human need, necessary for happiness. This month we’ll explore this idea that recovery is easier when we feel a sense of community.

In the opening sentence of his autobiography, Eric Clapton tells us, “From an early age…I began to get the feeling that I was different.” Clapton would soon turn to drugs and alcohol. The addict-playwright, Eugene O’Neill, described himself as someone who always felt that he was “a stranger who never feels at home…who can never belong.” O’Neill, like Clapton, became an addict.

These are typical descriptions of those who will eventually succumb to addiction. Experts have been doing a lot of research trying to figure out why one person who tries a drug does not turn into an addict, while another does. We’ve discovered that those who feel somehow different from most people, somehow separate from others, not ‘part of’, no sense of really belonging in the world … are vulnerable to addiction.

If you have struggled with drugs and alcohol, this may make a lot of sense. Think back to your life. Did you feel you were somehow different from others? Did you experience some trauma, making you feel that the world is a dangerous place where you must always be on guard? Or perhaps you were shy. Perhaps you were teased. But it doesn’t have to be a ‘negative’ condition. Maybe you were the star athlete or the smartest kid in school or came from the richest family. If others put you on a pedestal, you can also feel that you are different, that you’re not like other people.

One addictions counselor describes the addict as the kid peering into the candy shop window, hoping that someone will let him in. Not a bad description.

A tactic that most people who lack a sense of belonging use is to search out others who also feel they are different, who feel they do not really belong. It seems that feeling alone for any length of time is extremely uncomfortable. So people who feel they are ‘outcasts’ often hang around other ‘outcasts’ because they at least find some consolation.

The Brain Chemistry of Support

Alumni of the program at Sunshine Coast may recall a talk on Drugs & Your Brain, in which we described a remarkable thing. Being around supportive people actually increases a chemical in your brain called serotonin, known as the ‘happy drug.’ When you have serotonin flowing, you feel better. This is what many antidepressants (the SSRIs: Selective Serotonin Reuptake Inhibitors) do for you, by the way.

Of course, the reverse is also true. If you lock yourself away or if you feel shy at parties or if you feel you don’t really fit in at an AA meeting, then your serotonin levels drop (what scientists call low serotonin turnover).

In addition to supportive people increasing serotonin levels, many scientists now believe that we are “hard-wired” to be around others. What they mean by this is that human evolution seems to have designed us to be with others. Roy Baumeister, one of the great social psychologists, gave a talk in Toronto a few weeks ago arguing that human children take so long to develop because they have to learn (biologically and psychologically) how to live with other human beings.

Recovery and Connecting with Others

There is a video from Hazelden Treatment Center, the most famous addiction treatment center in the world, which talks about the necessity of connecting with others at a deep emotional level.

The fellow giving the talk in the video is a Roman Catholic priest, Steve Little. Although Rev. Little does not say so, he borrows an idea from a very famous thinker, Martin Buber. Buber wrote a little book called, I and Thou, which became a bestseller. The title refers to a deep connection with another person. When you are truly interested in another, you feel a connection: I-You. In contrast, if you don’t have this connection, you treat another as an object: I-It. The ‘You’ has been replaced with ‘It.’ This is how addicts in active addiction treat others. Think of how many people in addiction used others as objects: ‘Hey, would you give me a ride to town?’ Or they pretend to be interested in another when actually they just want something from them: ‘My you’re looking good today; can I bum a smoke?’ Or they dismiss another human being without even knowing anything about him: ‘He’s a jerk.’

Buber says that if we do not form a real connection with others, then we lose out. Life is dull and unsatisfying. But perhaps the greatest misery of having no deep relationship with others is loneliness. And as we all know, loneliness is one of the worst things about addiction. So one of the keys to overcome loneliness, one of the keys to recovery, is to start having genuine encounters with others.

A Lesson from Eric Clapton

After his plunge into sex, drugs, and rock-blues, Eric Clapton sobered up at age 42. He talks about the two times he went to a residential treatment center and the new way of life he found in recovery. Throughout, he had people supporting him.

Looking back on the last decade of his life (he’s now 62), Clapton writes: “The last ten years have been the best of my life. They have been filled with love and a deep sense of satisfaction, not because of what I feel I have achieved, but more because of what has been bestowed on me. I have a loving family….”

He goes on to mention his belief that he is a teacher and a healer through his music. But it is very clear that this new feeling comes from deep emotional connections with others. Once he began appreciating the others in his life, “full of love and laughter,” he could finally say, “I am very happy….”

There’s a lesson in this. Clapton confirms what we have known for millennia: human beings need to live in a community where they feel a sense of belonging, where they are part of, where they do not feel different, where they are not alone.

How Sunshine Coast Alumni Stay Connected

When clients leave Sunshine Coast, they are given the contact information of a former client. For clients, having an alumni contact is just one of many “tools” that they have out of their recovery toolkit. But like any tool, it’s useless if clients do not use it.

As clients say goodbye to their peers in their days at the center, the most common thing said is how grateful the client are to their peers. “I would never have made it without you guys.” Despite all the petty bickering and little conflicts, the connection clients make with their peers has a huge, lasting impact.

Many alumni make a special effort to meet up with other alumni when they travel to different cities. They tell us that these connections help them in their recovery.

And they even tell us that when they discover an alumnus is struggling, they find a sense of purpose in offering their support. Perhaps recovery works like this: Yesterday, Harry felt down and Tom lifted his spirits; today, Tom feels down, and Harry helps him.  

Here are some comments that alumni have told us about the help they have received from each other and from staying in touch with Sunshine Coast:

“I passed along the online support topic to an alumnus who was struggling; he said it was helpful.”

“I’ve been trying to arrange an alumni aftercare group. My phone is always ringing. If nothing else, this contacting people will keep me clean.”

“I wake up each Sunday and call peers. Even if they slip I call and offer my support.”

“Calling Sunshine Coast every once in a while helps keep me connected.”

“Darren (Sunshine Coast Alumni Coordinator) keeps me centered because he contacts me when I fill out the online program and aftercare workbook.”

About the Author

Geoff Thompson, MA, is the Program Director at Sunshine Coast Health Center, a private addiction treatment facility for adult men. His book, A Long Night’s Journey into Day, explores Eugene O’Neill’s life to uncover the truth of addiction and recovery.