Recovery Upgraded to Discovery – A New Model for Addiction
Discovery – an upgrade over recovery . The words we use effect our perceptions and inform our actions.
Some time ago I was sitting with a patient, recently discharged from a dual-diagnosis program. At a point during our initial interview, he asked if I wanted to know how far along he was in his ‘recovery’. I watched him closely as he expressed his struggle through various steps in NA, gave a count of his days clean, the number of meetings he’s attended, his frustration of trying to find a sponsor, etc. It was obvious he was trying to do the ‘right’ thing but there was something missing. And then it dawned on me (actually it hit me like a ton of bricks)… our current model of recover y has inadvertently built itself on covering over and covering up. In fact, what was missing was him. He was some where in there beneath the diagnoses heaped upon all the other stuff which had obscured him for years.
Stopping him midway, I heard myself say, “I’m not interested in your recovery”. Waiting for this to sink in (for both of us), I added, “You know what, I am interested in your un-covery of things and discovery of where you are in the midst of all of this.” At first he didn’t know how to respond (which is actually what I was going for). I wanted him to step away from the addict story and patent addiction lingo. Then he visibly relaxed, shifted back in the chair (away from the edge where he seemed either eager to please and/or ready to run), took a deep breath and said, “Oh, o.k.…. I get it”. He showed up.
This session set the tenor for the rest of our work together; a process of personal discovery rather than putting a lid back on and tidily placing things into categorical boxes with formulaic approaches and responses. Sometimes it was messy, but that’s how life is. If we don’t sweep them under the carpet, our messes and times of chaos are our finest teachers and moments for radical shifts. He eventually discovered the power to say no to what didn’t agree with him, to allow him self more and more yes’s (as he got reacquainted with his own values, hopes and dreams), ask for help at times and increasingly realize the unique attributes he could bring to the world. He grew to express the full breadth of his emotions (including when something angered him, not waiting until he was about to explode from days, months and years of repression).
The way things stand now, we expect recipients of care and providers to embrace a certain illness model; primarily relying on the Alcoholics Anonymous tenets of lifelong: meetings, abstinence, sponsorships, and referring to oneself as an addict (above all other self-descriptors). Yet, research indicates this model only works 5-7% of the time. If a person does not succeed, they’re typically told they haven’t hit rock bottom yet or are resistant. This is a travesty. Where else in medicine would we dispense a treatment with this low efficacy rate and hold the patient fully accountable when it is not successful? We must do better than this.
Juxtapose recovery models with what research indicates actually helps.
Nine studies have followed up with over 2000 people over a period averaging 20 years. They found the majority of people diagnosed with a major mental illness do get better. They also discovered that helping people focus on the following attributes provided the highest rates of permanent improvement:
- Making their own decisions
- Having a fulfilling network of connections, with primary supports outside the mental health system, (not a continual dependence on providers or support groups)
- Having a major social role other than consumer
- Using emotional distress as an opportunity for growth
- Development of new meaning and purpose as one grows beyond the catastrophe of illness
- Establishment of a positive sense of identity founded on hopefulness and self-determination.
- Engaging in the process of personal discovery of how to live (and how to live well) with enduring vulnerabilities ( Roberts & Wolfson, 2004)
Corroborating this, a recent review focused on different modalities for adolescent substance use, including 12-step AA models, cognitive behavioral therapy, motivation-based therapy, family-based intervention, and mixed or other approaches. A consistent pattern emerged that showed family-based intervention, CBT, and motivational enhancement therapy had the best outcomes. (Tanner-Smith EE, Wilson SJ, Lipsey MW. A comparative effectiveness of outpatient treatment for adolescent substance abuse: a meta-analysis. J Subst Abuse Treat. 2013;44:145-158.) It is highly likely, when the AA model is effective it is because of the connection and ‘purpose’ this approach temporarily offers, but what if we addressed other options for connection and we offered alternate paths for attaining meaning which didn’t necessitate lifelong identification as an addict? What if we more readily offered natural and biochemical support for healing a high-jacked brain? My guess is we would see much higher rates of lasting success. The ‘addict’ would be free to discover the full gamut of who they are. He or she would have the support to move beyond ‘addiction to treatment’. All of us do better when we’re moving towards something which inspires us rather than living a life of ‘management mode’.
As people heal they typically progress through four stages; first, dependent and unaware (here the person defers completely to those outside themselves for care and expertise), next, dependent and aware (with guidance the person begins exploring thoughts and patterns; bringing their subconscious to light), third, independent and aware (the person has a good grasp of their issues and wants to go it alone), but finally, the healthiest and most enduring stage of healing emerges (awareness accompanied by the realization we are all connected). While we speak of compliance as a positive treatment marker in actuality it is the patient who is a bit obstreperous who does much better in the long run, not the person who is dependent on an external plan of care. The single most stated phrase prior to a personal shift is, “I realized no one would do this for me….it was up to me.” This statement signifies an awakening to one’s own innate strength. Self agency is a hugely powerful healing force in all illness. Systems which encourage continued dependence on professionals or external structures and/or cementing an identity of ‘recovering addict’ (replete with operating instructions), actually thwart a person’s full healing. Healing goes beyond this.
The importance of concepts like: personal discovery, empowerment and interdependence, sync perfectly with the ground-breaking work of Dr. Lance Dodes. In The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, 2014, Dr Lance Dodes points out addiction is much more so a psychological response than a disease. While some people may have a genetic predisposition, we now know that genes are malleable; whether or not they are expressed is largely state dependent. Telling someone they have an illness for the rest of their life contributes to a state of powerlessness and hopelessness which is apt to dampen self-agency.
The prime cause of addictive behavior, according to Dr. Dodes, turns out to be subconscious suppression of ‘self’; denial of one’s personal power and uniqueness. After years of working with addictive behavior Dr. Dodes discovered prior to relapse, individuals unanimously reported experiencing a moment of seemingly intolerable frustration where he or she basically thought, “Fuck it” and decided to use. Rather than falling back on the, “90 meetings in 90 days” stance to address the relapse, Dr. Dodes explored the events immediately preceding the relapse. He realized these were situations where the person was invariably angry about something (usually related to acquiescence), but rather than expressing this, and taking healthier action, they turned to ‘using’ as a way to manage. He found, as soon as the person made the decision to use, they felt calm. It was not the substance (they hadn’t even taken it yet) but the act of deciding to take action, which calmed their system. At the time, reverting to the substance seemed like the perfect solution; it was defiant, decisive, and expressed the contained anger (both at self and others). However, while the drive was healthy, their choice of ‘how’ to actualize this continued to suppress the full ‘truth’ of the individual. These are the same dynamics I’ve noticed in working with addictions as well. In 39 years of practice I’ve found the majority of people who suffer emotionally tend to defer themselves in the interest of others; they are typically the ones who absorb the distress around them and bury it away. Who they are as individuals is lost beneath all this. Oddly, the attention the addiction gets often casts this person in a selfish light which is far from the truth and leads to increased misunderstanding.
As Dr. Dodes continually drilled down into these issues of powerlessness, anger and displacement, his patients really started getting somewhere. They began identifying their own patterns and got in touch with the healthy desires that lay beneath them. Eventually, as they felt worthwhile enough to own their power, become decisive, express themselves, and cease apologizing for who they are, their ‘need’ for substances gradually abated… all on its own . It no longer held its appeal. It turns out the primary path to wellness was one of continual un-covery and discovery.
Given all these findings, (once a person is chemically stable), psychotherapy turns out to be the best treatment for addictive behaviors; more specifically, psychotherapy with an integrative perspective (where the uniqueness of each individual is honored). Our treatment centers need to highlight approaches which foster self exploration, expression, evolution and exchange with others. We need to educate and re-educate and re-educate people about the central issues of powerlessness and refrain from further marginalizing people from the ‘family of man’ into a segregated family of ‘addicts’. We need to involve families in this process of discovery too; providing them with a path other than one of helplessness and disempowerment. Engaging in personal discovery, where explanations (not excuses) are unearthed is very different from enabling. While ‘enabling’ does involve covering over issues and/or supporting habits, it does not end with simply pulling resources away from the individual abusing substances. It also requires a willingness and learned ability to emotionally handle the expression of that person’s (sometimes angry but ultimately healthy) drive against helplessness, and powerless. This kind of family work is in keeping with the Finnish Open Dialogue Method where all members of the family, significant others, ‘identified patient’ and care providers work openly and transparently together, exploring the meaning behind everyone’s thoughts and behaviors, identifying potential ways to create improvement, and making decisions together. Embracing uncertainty and refraining from hasty or formulaic solutions is paramount here. It is a discovery model in the purest sense and it happens to post very high rates of well-being, even in cases of protracted psychosis.
It’s time to upgrade our mental health field, community and culture with a new language and understanding regarding addiction. We are missing the major issues and also early red flags. Unfortunately in the case of drugs, the problems take a more obvious and rapid toll on a person’s life, but addiction is rampant in our society. We have an entire selection of things we do with our ‘fuck it’ moments of suppressed feelings; we eat, work 70 hours a week, spend hours on the internet, indoors and isolated and even exercise excessively. Lots of us aren’t living balanced, fulfilling lives. Most of us could use help with expressing our authentic selves. In fact, not expressing our unique individuality turns out to top the list of regrets we carry in life.
What if, as a culture, we adopted un-covering and discovering as the go-to strategy for dealing with our emotional pain instead of the false notion that expression is some how weak, dangerous, or intolerable…it would be an entirely different ball game. By virtue of listening to others we would realize we are not alone, and we would learn various strategies for moving through difficult times. We would end up mobilizing the number one factor in healing – connection.
We would also come to recognize pain as a signal to pay attention, rather than our knee-jerk response of immediately wanting to suppress it. This would hopefully trickle in to how we manage physical pain, lessening our growing dependence on pain-killers to begin with; widening the opportunity for learning other effective, non-addictive options. All of us would stand to benefit from this kind of interdependent and self-aware healing.
Please take a moment and very seriously consider how our current paradigm of addiction treatment could be upgraded by an ‘uncovering and discovering’ mind-shift. If you, the reader, are a mental health professional, think how this new perspective might improve your outcomes. If you are an avid supporter of the AA model, rather than shutting your mind to these ideas, consider ways to augment the assets of this model to increase its effectiveness. Perhaps having people introduce themselves by their personal successes, hopes and dreams might be a welcome addition, for example. If your setting has already adopted a model of Discovery but just isn’t blatant about it, please share your findings and get the word out. It will help lift the stigma of addiction and remove a huge barrier to appropriate care.
Most importantly, if you, the reader, have suffered with addiction, the next time some one asks you about your ‘recovery’ please don’t hesitate to make a helpful correction some where along the lines of, “Thanks for asking, but I’m on an amazing journey of self-discovery.” I guarantee you will open the door, even just a bit, for the person to do the same for themselves. In the words of Lao Tzu,
"If you want to awaken all of humanity, then awaken all of yourself. If you want to eliminate the suffering in the world, then eliminate the dark and negative in yourself. Truly, the greatest gift you have to give is that of your own self-transformation."
Heidi Waltos, CNS, MSN, Psychotherapist, May 21, 2016