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.

Often when families call our treatment center for help, they often struggle with being uncertain whether or not their loved one has an addiction. Even professionals in the field sometimes confuse addiction with substance abuse so it’s not surprising when families have trouble telling the difference. While there are a number of tests out there, we recommend a very simple test we call the “3 Cs of Addiction.”

Basically, the 3 Cs stand for 3 characteristics that must be present in order for a bad habit to be considered an addiction. An addiction can be to a substance such as drugs or alcohol, or to a process like gambling or sex.

Unfortunately, the word ‘addiction’ has become part of pop culture and is increasingly being used to describe anything that brings so much pleasure that one can’t help themselves. Chocolate and coffee are common examples, neither of which meet the criteria for a true addiction. This can be better understood with a review of the 3 Cs as follows:

C #1 - Compulsion

Compulsion is obsessive behaviour that individuals demonstrate when it comes to their bad habit. The key here is that compulsion happens before the individual indulges in their bad habit. Examples include:

- excessively talking about your bad habit

- daydreaming about your bad habit

- spending most or all of your time with people that share your bad habit

- scheduling your day around your bad habit

C #2 - Control

Control refers to what happens after you start consuming or participating in your bad habit. Once started, people who have no control have an inability to:

- set limits on the amount consumed

- honour basic commitments such as oral hygiene, housekeeping, making dinner for your kids, or showing up for work

- engage in risky behaviour that endangers the health or well-being of one’s self or others

C #3 - Consequences

A consequence is defined as the outcome of an action. In order for a bad habit to qualify for C #3 the consequence has to be of the negative variety and the bad habit must continue in spite of continued negative consequences. Examples include:

- continuing with the bad habit even after your doctor warns you it is killing you

- repeatedly getting into trouble with the police

- falling in debt but continuing to spend on your bad habit

- refusing to quit your bad habit even after your spouse leaves you

The Most Important C: Consequence

It is important to note that having one 2 out of 3 of the characteristics would suggest that an individual is only abusing a substance or a process. Typically, the ‘C’ that separates most people with dependencies from those that only abuse is consequences. For most individuals, when the consequences of continued abuse get bad enough, the individual typically stops or cuts back. Not so for the addict.

Applying Specific Bad Habits to the 3 Cs of Addiction Test

Let’s look at some specific bad habits to see if they are true addictions based on the criteria established by this test:

Coffee - coffee can be a morning ritual which could narrowly count as C #2 - compulsion. However, most people rarely drink more than a few cups a day (C #1 - control). As for consequences, coffee doesn’t fit the bill. You may get cranky if you have too much caffeine and it may even stain your teeth or give you bad breath but these consequences are not grave enough to meet the 3 C criteria.

Internet Gaming - many children and teenagers are spending excessive time playing online video games. These games can range from single-player to massively multiplayer online role-playing games (MMORPG)  where hundreds, even thousands, can be playing the same game online. Popular MMORPG titles include the World of Warcraft and Maple Story. Internet gaming also includes online gambling which is now a multi-billion dollar industry (see the Gambling section below).

Individuals who participate in online gaming certainly exhibit clear signs of an inability to control the amount of time they spend playing once they start. Online gamers also exhibit signs of compulsion as many kids will find other ways to play even when their parents restrict their use such as going over to a friend’s house to play or going to the local internet cafe. As for consequences, the biggest negative consequence is the amount of time lost to being on the computer. This is time that could arguably be spent involved in other more fulfilling activities. Whether wasting time, however, can be considered a negative consequence is debatable. 

Sex Addiction - Patrick Carnes, a noted psychologist and author on sex addiction refers to sex addiction as “a compulsive behaviour that completely dominate’s an addict’s life and can include: compulsive masturbation, compulsive heterosexual and homosexual relationships, pornography, prostitution, exhibitionism, voyeurism, indecent phone calls, child molesting, incest, rape and violence.” Patrick Carnes even describes sexual anorexia, similar to eating disorders, is a form of addiction where depriving oneself of sex can create feelings of power and invincibility from emotional pain.

However, many other sex experts, particularly sexologists, argue that compulsive sexual behaviour is not an addiction since sex is a perfectly natural activity, necessary for reproduction.

The Diagnostic and Statistical Manual of Psychiatric Disorders, Volume Four describes sex addiction, under the category “Sexual Disorders Not Otherwise Specified,” as “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.” According to the manual, sex addiction also involves “compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship.”

Sexual compulsivity, however, definitely meets the criteria for the 3 C Addiction Test since marital breakup is often the result of those who choose to engage in prostitution, internet porn while incest, rape and voyeurism can and does lead to legal problems. However, such behaviours must be repeated in spite of negative consequences in order to meet the 3 C criteria.

Gambling - one of the better known addictions, can certainly lead to compulsive behaviour as many gamblers have been known to spend hours away trying to figure out how to beat the house. As for control, many gamblers have been known to promise themselves they would limit their bets to $100 and end up losing their homes by the end of the evening. The consequences of gambling can range from personal bankruptcy to divorce. For the addict, however, superstition and a distortion of the real odds of winning keep the compulsive gambler coming back for more.

Alcohol - I intentionally left alcohol to the end after reading an interesting 12 Step study guide titled, “A Program for You: A Guide to the Big Book’s Design for Living.” Of interest in this book is how the Big Book distinguishes between the 3 Cs of addiction, albeit using a different terminology. For example, the Big Book uses the following terminology:

compulsion = a mental obsession

In the Big Book, Dr. Silkworth describes how alcoholics often feel: restless, irritable, and discontented when they’re sober. Over time, the alcoholic begins to believe that taking a drink will relieve these feelings until the idea becomes an obsession.

control = a physical craving

The physical craving is part of what the Big Book refers to as an “allergy to alcohol” or a “reaction to having alcohol in our system.” According to A Program for You, the word “craving” always refers to the body.

What the Big Book says About Other Types of Addictions

According to A Program for You, the Big Book recognizes that there are different kinds of obsessions such as compulsive overeating, and gambling. Both of these obsessions lead to “lives exactly like those of alcoholics who are still drinking”: They go on binges, then swear they will never do it again. But sooner or later, they start feeling restless, irritable, and discontented. Then the obsession kicks in and their minds convince them that a little bit wouldn’t hurt.

Interestingly, A Program for You concludes that “all obsessions are pretty much the same. The fact that we’re allergic to alcohol isn’t what’s most important. The important thing is that we have an obsession in our mind.”

Conclusion

So, remember, the next time you hear the word “addiction” being used in the media keep in mind that true addictions should meet the three criteria: compulsion, control, and consequences.

Self-Help Groups

Gamblers Anonymous

Overeaters Anonymous

Sex Addicts Anonymous